THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


PRACTICAL  TREATISE 


ON 


FRACTURES  AND  DISLOCATIONS. 


BY 


FRANK  HASTINGS  HAMILTON,  A.M.,  M.D.,  LL.D., 

PROFESSOR  OF  THE  PRACTICE  OF  SURQEKT  WITH  OPERATIONS,   IN  BELLEVUE  HOSPITAL  MEDICAL  COLLEOE; 

SURUEOX  TO  BELLEVUE  HOSPITAL,  NEW  YORK  ;  CONSULTINO  SURGIEON  TO  HOSPITAL  FOR  RUPTLRED 

AND  CRIPPLES  ;   AUTHOR  OF  A  TREATISE  ON  MILITARY  SURUERY  AND  HTOIENE. 


FOURTH  EDITION, 
EEVISED  AND  IMPROVED. 

ILLUSTRATED    -WITH 

THREE  HUNDRED  AND  TWENTY-TWO  WOOD-CUTS. 


PHILADELPHIA: 

he:n"et   c.   lea. 

1871. 


Entered  according  to  the  Act  of  Congress,  in  the  year  1871,  by 

HENRY    C.    LE  A, 
in  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


PHILADELPHIA  : 
COLLINS,  PRINTER,  705  JAVNE  STREET. 


1?7| 


PREFACE  TO  THE  FOURTH  EDITIOJ(. 


Discussioxs  wliicli  occupied  considerable  space  in  previous  editions 
Lave  been  omitted  in  the  present ;  such,  for  example,  as  that  relating 
to  the  value  of  certain  specimens  claiming  to  represent  bony  union 
after  intra-capsular  fractures  of  the  neck  of  the  femur.  Many  obsolete 
forms  of  apparatus  have,  also,  been  excluded.  This  has  been  done  to 
make  room  for  the  more  practical  observations,  and  more  ef&cient 
apparel  which  later  experience  has  supplied.  Nearly  one-fourth  of 
the  whole  number  of  illustrations  has  been  changed,  and  in  most 
cases  by  the  substitution  of  original  wood-cuts.  The  volume  has 
been  especially  enriched  by  the  introduction  of  several  of  the  beauti- 
ful illustrations  contained  in  Dr.  Bigelow's  treatise  on  The  Mechanism 
of  Dislocation  and  Fracture  of  the  Hip.  Since  Sir  Astley  Cooper 
wrote,  probably  no  one  man  has  thrown  so  much  light  upon  the  sub- 
ject of  hip-joint  accidents,  or  contributed  so  much  toward  an  accurate 
and  systematic  plan  of  treatment,  as  the  distinguished  Boston  sur- 
geon. 

During  the  last  fifteen  or  twenty  years,  the  progress  of  knowledge 
in  the  diagnosis,  pathology,  and  treatment  of  both  fractures  and  dis- 
locatiotis  has  been  steady  and  rapid.  Diagnosis  has  been  rendered 
more  accurate,  treatment  has  acquired  a  more  scientific  basis,  and 
results  are  in  an  appreciable  degree  more  satisfactory.  The  occasion 
seems  suitable,  therefore,  to  remind  the  reader  of  the  excellent  and 
inspiring  words  of  Pearson : — 
. "  If  the  prospect  of  that  which  remains  to  be  done,  after  the  lapse 


iv  PREFACE  TO  THE  FOUETH  EDITION. 

of  SO  many  a'ges,  tends  to  abate  hope  and  discourage  endeavor,  yet  it 
should  be  remembered  that  no  man  can  determine  the  measure  of 
success  which  may  be  connected  with  industrious  research  and  zeal- 
ous exertion." 

43  "West  32d  Strket,  N.Y., 
July  1,  1871. 


PREFACE  TO  THE  FIRST  EDITION 


The  English  language  does  not  at  this  moment  contain  a  single  com- 
plete treatise  on  Fractures  and  Dislocations.  The  two  small  volumes 
of  Desault,  and  the  one  of  Boyer,  issued  near  the  close  of  the  last 
century,  and  translated  into  English  early  in  this,  may  perhaps  pro- 
perly enough  have  been  regarded  as  complete  treatises  at  the  time 
of  their  publication,  but  they  certainly  cannot  be  so  considered  now. 
The  several  chapters  on  "Diseases  and  Injuries  of  the  Bones,''''  contained 
in  the  Lecons  Orales  of  Dupuytren,  translated  in  1846,  and  the  Trea- 
tise on  Fractures  in  the  Vicinity  of  the  Joints,  and  on  Certain  Forms  of 
Accidental  and  Congenital Dislocations,hy^o\>QVt'&m.\\h.,^rQ  invaluable 
monographs,  but  neither  of  them  claims  to  be  anything  more  than  a 
collection  of  occasional  and  miscellaneous  papers.  The  writings  of 
Amesbury  and  of  Lonsdale  relate  only  to  fractures.  Even  the  justly 
celebrated  quarto  of  Sir  Astley  Cooper  is  no  more  than  what  its  title 
plainly  declares  it  to  be,  A  Treatise  on  Dislocations  and  on  Fractures  of 
the  Joints;  but  since  the  announcement  of  the  present  volume,  a  trans- 
lation of  Malgaigne's  great  and  crowning  work  on  Fractures  and 
Dislocations  has  been  commenced  by  Dr.  Packard,  of  Philadelphia, 
and  the  first  volume  has  been  placed  in  the  hands  of  the  American 
profession.  Should  the  remaining  volume  be  rendered  iuto  English, 
the  gap  in  our  literature  will  be  measurably  filled. 

Under  these  circumstances  I  might  scarcely  have  thought  it  worth 
while  to  continue  my  labors,  already  so  near  their  completion,  had  it 
not  seemed  to  me  that  Malgaigne,  whose  researches  have  been  truly 
marvellous,  had  failed  in  some  measure  to  give  a  just  representation 
of  the  observations  and  improvements  which  have  been  made  from 
time  to  time  by  my  own  countrymen. 

Th  econtributions  of  American  surgeons  to  this  department  had  to 
be  sought  chiefly  in  medical  journals,  many  of  which  have  long  been 
discontinued,  and  most  of  which  were  inaccessible  to  the  great  French 
writer.     Even  to  an  American,  the  labor  of  exhumation  from  archives 


Vi  PREFACE    TO    THE    FIRST    EDITION. 

hitherto  almost  unexplored  has  not  been  small ;  and  it  is  probable 
that  many  valuable  papers  have  been  overlooked;  indeed  it  is  impos- 
sible that  it  should  be  otherwise. 

I  am  free  to  say,  also,  that  I  have  been  encouraged  by  a  hope  that 
my  own  personal  experience,  obtained  during  many  years  of  public 
and  private  service,  might  be  of  some  value  to  my  contemporaries. 

Very  little  space  has  been  devoted  to  what  is  now  only  historical, 
except  so  far  as  was  necessary  to  correct  certain  time-consecrated 
errors,  or  to  confirm  and  illustrate  the  practice  of  the  present  day ; 
but  by  a  pretty  full  report  of  characteristic  examples,  selected  from 
more  than  one  thousand  cases  already  published  by  myself,  by  copious 
references  to  the  examples  recorded  by  others,  and  by  a  careful  exclu- 
sion of  whatever  has  not  been  confirmed  by  experience  or  established 
by  dissection,  I  have  endeavored  to  make  this  treatise  useful  both  to 
the  student  and  practical  man,  and  a  reliable  exponent  of  the  present 
state  of  our  art  upon  those  subjects  of  which  it  treats. 

In  order  to  render  the  description  of  the  various  forms  of  apparatus 
employed  in  the  treatment  of  fractures  more  intelligible,  and  to  avoid 
the  necessity  of  lengthened  explanations,  a  large  number  of  illustra- 
tions have  been  introduced,  more,  perhaps,  than  might  be  thought 
necessary,  especially  as  in  several  instances  the  apparel  which  is  figured 
is  not  that  which  is  recommended  by  the  author.  It  is  believed,  how- 
ever, that  by  a  study  of  the  principal  forms  of  approved  dressings  the 
reader  will  be  better  prepared  for  the  exigencies  of  practice  ;  and  that 
by  the  simultaneous  presentation  of  those  which  are  not  approved,  he 
will  be  saved  from  a  wasteful  expenditure  of  his  time  in  the  contriv- 
ance of  useless  apparatus.  It  is  not  in  the  discovery  and  multiplica- 
tion of  mechanical  expedients  that  the  surgeon  of  this  day  declares  his 
superiority,  so  much  as  in  the  skilful  and  judicious  employment  of 
those  which  are  already  invented. 

The  author  desires  to  acknowledge  his  indebtedness  to  very  many 
of  his  professional  brethren,  throughout  the  United  States,  for  the 
promptness  with  which  they  have  responded  from  time  to  time  to  his 
inquiries,  and  for  the  generosity  with  which  they  have  opened  their 
pathological  collections  and  placed  valuable  specimens  at  his  disposal. 

He  wishes  also  to  express  his  special  obligations  to  Dr.  J.  E.  Lothrop, 
of  this  city,  who  has  kindly  aided  him  in  revising  most  of  the  proof- 
sheets  as  they  have  been  issued  from  the  press. 

FliANK  H.  HAMILTON. 

Buffalo,  N.Y.,  December,  1859. 


CONTENTS. 


PAET  I. 

FEACTURES. 
CHAPTER    I. 

PAGE 

General  Division  op  Fractures      ......        27 

CHAPTER    II. 

General  Etiology  op  Fractures     ......        29 

CHAPTER    III. 

General  Semeiology  and  Diagnosis  .  .  .  .  .33 

CHAPTER    lY. 

Repair  of  Broken  Bones       .......        38; 

CHAPTER    Y. 

General  Treatment  op  Fractures  .....        M 

CHAPTER    YI. 

Delayed  Union  AND  Non-Union  OF  Broken  Bones  .  .  .62 

CHAPTER    YII. 

Bending,  Partial  Fractures,  and  Fissures  of  the  Long  Bones         .        72 
§1.  Bending  of  the  Long  Bones     ......        72 

§  2.  Partial  Fracture  of  the  Long  Bones    .  .  .  .  .76 

§  3.  Fissures  .........        84 

CHAPTER    YIII. 

Fractures  op  the  Nose  .  .  .  .  .  .  .89 

§  1.  Ossa  Nasi  ......."..        89 

§  2.  Fractures  and  Displacements  of  the  Septum  Narium  .  .94 


VUl 


CONTENTS. 


CHAPTER    IX. 

Fractures  of  the  Malar  Bone 

CHAPTER    X. 

Fractures  of  the  Upper  Maxillary  Bones 

CHAPTER    XI. 

Fractures  of  the  Zygomatic  Arch 

CHAPTER    XII. 

Fractures  of  the  Lower  Jaw 


PAGE 

97 


.      100 


lOG 


109 


CHAPTER    XIII. 

Fractures  of  the  Hyoid  Bone 

CHAPTER    XIV. 

Fractures  of  the  Cartilages  of  the  Larynx 
g  1.  Thyroid  Cartilage         .  .  .  . 

§  2.  Thyroid  and  Cricoid  Cartilages 
S  3.  Cricoid  Cartilage  .  •  .  . 


133 


138 
138 
138 
140 


CHAPTER    XV. 

Fractures  of  the  Vertebrae 

§  1.  Fractures  of  the  Spinous  Processes     . 
§  2.  Fractures  of  the  Transverse  Processes 
§  3.  Fractures  of  the  Vertebral  Arches 
§  4.  Fractures  of  the  Bodies  of  the  Vertebrae 

1.  Fractures  of  the  Bodies  of  the  Lumbar  Vertebrae 
3.  Fractures  of  the  Bodies  of  the  Dorsal  VertebrsB 

3.  Fractures  of  the  Bodies  of  the  five  lower  Cervical  Vertebra? 

4.  Treatment  of  Fractures  of  the  Bodies  of  the  Vertebrae 
§  5.  Fractures  of  the  Axis  ...... 

§  6.  Fractures  of  the  Atlas  ...... 

§  7.  Fractures  of  the  first  two  Cervical  Vertebrae  (Atlas  and  Axis)  at 
the  same  time  ...... 

CHAPTER    XVI. 

Fractures  op  the  Sternum  . 


143 
143 
144 
145 
151 
153 
154 
155 
158 
161 
164 

164 


165 


CHAPTER    XVII, 

Fractures  of  the  Ribs  and  their  Cartilages 
1 1.  Fractures  of  the  Ribs    .... 
g  2.  Fractures  of  the  Cartilages  of  the  Ribs 


173 
173 

177 


CONTENTS. 


IX 


CHAPTER    XVIII. 

PAGE 

Fractures  of  the  Clavicle   .......      178 

CHAPTER    XIX. 

Fractures  op  the  Scapula    .......      203 

§  1.  Fractures  of  the  Body  of  the  Scapula  ....       202 

§  2.  Fractures  of  the  Neck  of  the  Scapula  .  .  .  .206 

§  3.  Fractures  of  the  Acromion  Process     .....       208 

§  4.  Fractures  of  the  Coracoid  Process      .  .  .  .  .211 

CHAPTER    XX. 

Fractures  of  the  Humerus  .           .           .           .           .           .           .  213 

§1.  Fractures  of  the  Head  and  Anatomical  Neck  .  .  .215 

§  2.  Fractures  through  the  Tubercles         .....  219 

§  3.  Longitudinal  Fractures  of  the  Head  and  Neck,  or  Splitting  off  of 

the  Greater  Tubercle  .  .  .  .  .  .219 

§  4.  Fractures  through  the  Surgical  Neck  (including  Separations  at  the 

Upper  Epiphysis)        .......  221 

§  5.  Fractures  of  the  Shaft  below  the  Surgical  Neck,  and  above  the  Base 

of  the  Condyles         .......  234 

§  6.  Fractures  at  the  Base  of  the  Condyles  (including  Separations  of  the 

Lower  Epiphysis)       .......  245 

§  7.  Fractures  at  the  Base  of  the  Condyles,  complicated  with  Fracture 

between  the  Condyles,  extending  into  the  Joint     .            .            .  253 

§  8.  Fractures  of  the  Internal  Epicondyle              ....  256 

§  9.  Fractures  of  the  External  Epicondyle             ....  260 

§  10.  Fractures  of  the  Internal  Condyle     .....  261 

§  11.  Fractures  of  the  External  Condyle    .....  263 


CHAPTER    XXI. 

Fractures  of  the  Radius      .... 

CHAPTER    XXII. 

Fractures  op  the  Ulna         .... 

§  1.  Shaft  of  the  Ulna  .  .      '       . 

§  2.  Coronoid  Process  of  the  Ulna 

§  3.  Fractures  of  the  Olecranon  Process    . 


267 


297 
297 
301 
310 


CHAPTER    XXIII, 

Fractures  op  the  Radius  and  Ulna 


318 


CHAPTER    XXIV. 

Fractures  of  the  Carpal  Bones  . 


.       327 


CHAPTER    XXV. 

Fractures  op  the  Metacarpal  Bones 


328 


X  CONTENTS. 

CHAPTER    XXYI. 

Fkactukes  of  the  Fingers     ....... 

CHAPTER    XXVII. 

Fractures  of  the  Pelvis,  and  Traumatic  Separations  at  its  Sym- 


PAGE 

331 


hyses  ......••• 

334 

§  1.  Pubes     ........ 

335 

§  2.  Ischium              ....... 

338 

§  3.  Ilium      ........ 

340 

§  4.  Acetabulum       ....... 

343 

§  5.  Sacrum  ........ 

349 

§  6.  Coccyx  .           .           .            .            .            .            . 

351 

CHAPTER    XXVIII. 

Fractures  of  the  Femur       ....... 

§  1.  Neck  of  tlie  Femur       ....... 

(«.)  Neck  of  the  Femur  within  the  Capsule 

(5.)  Neck  of  the  Femur  without  the  Capsule 

(c.)  Fractures  of  the  Neck  partly  within  and  partly  without  the 
Capsule  ....... 

§  2.  Fracture  through  the  Trochanter  Major  and  Base  of  the  Neck  of 

the  Femur       .... 
§  3.  Fracture  of  the  Epiphysis  of  the  Trochanter  Major 
§  4.  Fractures  of  the  Shaft  of  the  Femur  . 
§  5.  Fractures  of  the  Condyles 

(a.)  Fractures  of  the  External  Condyle 

(5.)  Fractures  of  the  Internal  Condyle 

(c.)  Fractures  between  the  Condyles  and  across  the  Base 

CHAPTER    XXIX. 

Fractures  op  the  Patella    ...... 

CHAPTER    XXX. 

Fractures  of  the  Tibia         ...... 

CHAPTER    XXXI. 
Fractures  of  the  Fibula       ...... 

CHAPTER    XXXII. 

Fractures  of  the  Tibia  and  Fibula  .... 

CHAPTER    XXXIII. 

Fractures  op  the  Tarsal  Bones      ..... 

CHAPTER    XXXIV. 

Fractures  of  the  Metatarsal  Bones 


352 
352 
853 
376 

882 

383 
384 
386 
428 
428 
429 
431 


434 


444 


449 


453 


476 


481 


CO^^TENTS. 


XI 


CHAPTER    XXXY. 

Fractures  of  the  Phalanges  op  the  Toes 

CHAPTER    XXXYI. 

Gunshot  Fractures     ..... 


PAGE 

483 


483 


PAET    II. 


DISLOCATIONS. 


§2. 
§4. 


CHAPTER   I. 

General  Considerations 

§  1.  General  Division  and  Nomenclature 

General  Predisposing  Causes 

Direct  or  Exciting  Causes 

General  Symptoms 
§  5.  Pathology 
§  6.  General  Prognosis 
§  7.  General  Treatment 

CHAPTER    II. 

Dislocations  of  the  Lower  Jaw 

§  1.  Double  or  Bilateral  Dislocations 
§  2.  Single  or  Unilateral  Dislocations 
8  3.  Conditions  of  tlie  Jaw  simulating  Luxations 


493 
493 
494 
495 
495 
497 
498 
498 


501 
501 
505 
506 


CHAPTER    III. 

Dislocations  op  the  Spine     .......  508 

§  1.  Dislocations  of  the  Lumbar  Vertebrge  ....  509 

§  2.  Dislocations  of  the  Dorsal  Vertebras  .....  510 

§  3.  Dislocations  of  the  Six  Lower  Cervical  Vertebrae      .  .  .  513 

§  4.  Dislocations  of  the  Atlas         .  .....  519 

§  5.  Dislocations  of  the  Head  upon  the  Atlas,  or  Occipito-Atloidean 

Dislocations     ........  521 


CHAPTER    IV. 

Dislocations  of  the  Ribs        .  .  .  , 

§  1.  Dislocations  of  the  Ribs  from  the  Vertebrae  , 
§  2.  Dislocations  of  the  Ribs  from  the  Sternum 

§  3.  Dislocations  of  cue  Cartilage  upon  another  . 


521 
521 
523 
524 


PAGE 

524 
524 

528 
530 
532 
537 

538 
539 


xii  CONTENTS. 

CHAPTER    Y. 

Dislocations  of  the  Clavicle  ..... 

§  1.  Dislocations  Forwards  at  the  Sternal  End 

^  2.  Dislocations  of  the  Sternal  End  of  the  Clavicle  Upwards     . 

§  3.  Dislocations  of  the  Sternal  End  of  the  Clavicle  Backwards 

§  4.  Dislocations  of  the  Acromial  End  of  the  Clavicle  Upwards 

§  5.  Dislocations  of  the  Acromial  End  of  the  Clavicle  Downwards 

§  6.  Dislocations  of  the  Acromial  End  of  the  Clavicle  under  the  Coracoid 

Process  .....•• 

§  7.  Dislocation  of  the  Clavicle  at  both  Ends 

CHAPTER    Vr. 

Dislocations  op  the  Shoulder  (Humerus  at  its  Upper  Extremity)  540 
'§  1.  Dislocations  of  the  Shoulder  Downwards  (Subglenoid)        ,            .  540 
Dislocation,  with  Fracture  of  the  Humerus  near  its  Upper  End      .  565 
g  2.  Dislocations  of  the  Humerus  Forwards  (Subcoracoid  and  Subcla- 
vicular) .........  566 

§3.  Dislocations  of  the  Humerus  Backwards  (Subspinous)         .  .  573 

§  4.  Partial  Dislocations  of  the  Humerus  .....  576 

CHAPTER   YII. 

Dislocations  of  the  Head  of  the  Radius  .....  579 

§1.  Dislocations  of  the  Head  of  the  Radius  Forwards     .  .  .  579 

§  2.  Dislocations  of  the  Head  of  the  Radius  Backwards  .  .  .  584 

§  3.  Dislocations  of  the  Head  of  the  Radius  Outwards     .  .  ,  586 

CHAPTER   VIII. 

Dislocations  of  the  Upper  End  op  the  Ulna  Backwards         .  .      587 

CHA  PTER    IX. 

Dislocations  of  the  Radius  and  Ulna  (Forearm  at  the  Elbow-Joint)  588 

§  1.  Dislocations  of  the  Radius  and  Ulna  Backwards       .  .  .  588 

§  3.  Dislocations  of  the  Radius  and  Ulna  Outwards  (to  the  Radial  Side)  598 

§  3.  Dislocations  of  the  Radius  and  Ulna  Inwards  (to  the  Ulnar  Side)  .  603 

§  4.  Dislocations  of  the  Radius  and  Ulna  Forwards         .  .  .  605 

CHAPTER   X. 

Dislocations  op  the  Wrist  (Radio-Carpal  Articulation)       .  .      606 

§  1.  Dislocations  of  the  Carpal  Bones  Backwards  .  .  .608 

§  2.  Dislocations  of  the  Carpal  Bones  ForAvards   .  .  .  .611 

CHAPTER  XI. 

Dislocations  op  the  Lower  End  of  the  Ulna  (Inferior  Radio-Ulnar 

Articulation)  •  •  .  .  .  61'* 

§  1.  Dislocations  of  the  Lower  End  of  the  Ulna  Backwards       .  .  613 

§  2.  Dislocations  of  the  Lower  End  of  the  Ulna  Forwards  .  .  614 


COXTEXTS. 


XIU 


CHAPTER    XII. 

DlSLOCATIOIfS  OF  THE  CaRPAL  BoNES  (aMOXG  THEMSELVES) 


PAGE 
615 


CHAPTER    XIII. 

Dislocations  of  the  Metacarpal  Bones  (at  the  Carpo-Metacarpal 
Articulations)  .  .  .  .  .  .  .  .617 

CHAPTER    XIV. 

Dislocations  of  the  First  Phalanges  of  the  Thumb  and  Fingers  (at 

THE  Metacarpo-Piialangeal  Articulations)     ....  620 

§  1.  Dislocations  of  tlie  First  Phalanx  of  the  Thumb  Backwards           .  620 

§  2.  Dislocations  of  the  First  Phalanx  of  the  Thumb  Forwards              .  627 

§  3.  Dislocations  of  the  First  Phalanx  of  the  Fingers      .            ,            .  .628 


CHAPTER    XY. 

Dislocations  of  the  Second  and  Third  Phalanges  of  the  Thumb 
and  Fingers    .........      629 

CHAPTER    XVI. 

Dislocations  op  the  Thigh  (Coxo-Femoral)        ....      632 

g  1.  Dislocations  Upwards  and  Backwards  on  the  Dorsum  Ilii    .  .       634 

§  2.  Dislocations  Upwards  and   Backwards  into  the   Great  Ischiatic 

Notch  .........       660 

§  3.  Dislocations  Downwards  and  Forwards  into  the  Foramen  Thy- 

roideum  ........       668 

§  4.  Dislocations  Upwards  and  Forwards  upon  the  Pubes  .  .       674 

§  5.  Anomalous  Dislocations,  or  Dislocations  which  do  not  properly 

belong  to  either  of  the  four  principal  divisions  before  described      678 

1.  Dislocations  directly  Upwards    .....       678 

2.  Dislocations  Downwards  and  Backwards  upon  the  Posterior 

Part  of  the  Body  of  the  Ischium,  between  its  Tuberosity  and 

its  Spine   ........       682 

3.  Dislocations  Downwards  and   Backwards  into  the  Lesser  or 

Lower  Ischiatic  Notch    ......  682 

4.  Dislocations  directly  Downwards             ....  683 

5.  Dislocations  Forwards  into  the  Perineum  .  .  ,  684 
§  6.  Ancient  Dislocations  of  the  Femur  .....  686 
§  7.  Partial  Dislocations  of  the  Femur  ,  .  .  .  .690 
§  8.  Coxo-Femoral  Dislocations,  complicated  with  Fracture  of  the  Femur  691 
§  9.  Voluntary  Dislocations  of  the  Femur             ....  694 


CHAPTER    XVII. 

Dislocations  of  the  Patella 

§  1.  Dislocations  of  the  Patella  Outwards 
g  2.  Dislocations  of  the  Patella  Inwards    . 
§  3.  Dislocations  of  the  Patella  upon  its  Axis 
§  4.  Dislocations  of  the  Patella  Upwards  . 


690 
696 
699 
099 

702 


XIV 


CONTENTS. 


CHAPTER    XVIII. 

PAGE 

Dislocations  of  the  Head  op  the  Tibia     .            .            .            .  .      703 

§  1.  Dislocations  of  the  Head  of  the  Tibia  Backwards    .            .  .704 

§  2.  Dislocations  of  the  Head  of  the  Tibia  Forwards       .            .  .706 

§  3.  Dislocations  of  the  Head  of  the  Tibia  Outwards       .            .  .708 

§  4.  Dislocations  of  the  Head  of  the  Tibia  Inwards         .            .  .       709 

§  5.  Dislocations  of  the  Head  of  the  Tibia  Backwards  and  Outwards  .       710 

S  6.  Internal  Derangement  of  the  Knee-Joint       ....       711 


CHAPTER    XIX. 

Dislocations  op  the  Lower  End  op  the  Tibia     . 

§  1.  Dislocations  of  the  Lower  End  of  the  Tibia  Inwards 
§  2.  Dislocations  of  the  Lower  End  of  the  Tibia  Outwards 
§  3.  Dislocations  of  the  Lower  End  of  the  Tibia  Forwards 
8  4.  Dislocations  of  the  Lower  End  of  the  Tibia  Backwards 


713 
714 
718 
730 
724 


CHAPTER    XX. 

Dislocations  op  the  Upper  End  op  the  Fibula   . 

§  1.  Dislocations  of  the  Upper  End  of  the  Fibula  Forwards 
§  2.  Dislocations  of  the  Upper  End  of  the  Fibula  Backwards 


725 
725 
726 


CHAPT  ER    XXI. 

Dislocations  op  the  Inferior  Peroneo-Tibial  Articulation 


727 


CHAPTER    XXII. 


Tarsal  Luxations 


Dislocations  of  the  Astragalus    . 
Astragalo-Calcaneo-Scaphoid  Dislocations 
Dislocations  of  the  Calcaneum 
Middle  Tarsal  Dislocations 
Dislocations  of  the  Os  Cuboides 
§  6.  Dislocations  of  the  Os  Scaphoides 
§  7.  Dislocations  of  the  Cuneiform  Bones 


§1 

§3, 
§3 
§4 

§5, 


737 
727 
735 
736 
737 
737 
737 
738 


CHAPTER    XXIII. 

Dislocations  op  the  Metatarsal  Bones    . 


740 


CHAPTER    XXI Y. 

Dislocations  op  the  Phalanges  op  the  Toes 


743 


CHAPTER    XXV. 

Compound  Dislocations  of  the  Long  Bones 


743 


C  0  X  T  E  X  T  S . 


XV 


CHAPTER    XXVI. 

Congenital  Dislocations       .... 

§  1.  General  Observations  and  History 

§3.  Etiology  ..... 

§  3.  Congenital  Dislocations  of  the  Inferior  Maxilla 
§  4.  Congenital  Dislocations  of  the  Spine  . 
§  5.  Congenital  Dislocations  of  the  Pelvic  Bones 
§  6.  Congenital  Dislocations  of  the  Sternum 
§  7.  Congenital  Dislocations  of  the  Clavicle 
§  8.  Congenital  Dislocations  of  the  Shoulder  (Upper  End  of  the  Hume 
rus)      .......  . 

§  9.  Congenital  Dislocations  of  the  Radius  and  Ulna  Backwards 

§  10.  Congenital  Dislocations  of  the  Head  of  the  Radius 

§  11.  Congenital  Dislocations  of  the  Wrist 

§  13.  Congenital  Dislocations  of  the  Fingers 

§  13.  Congenital  Dislocations  of  the  Hip   . 

§  14.  Congenital  Dislocations  of  the  Patella 

^  15.  Congenital  Dislocations  of  the  Knee 

§  16.  Congenital  Dislocations  of  the  Tarsal  Bones 

§  17.  Congenital  Dislocations  of  the  Toes 


PAGE 

758 
758 
7G0 
761 
764 
7G5 
765 
766 

7GG 
770 
770 
771 

773 
773 
778 
779 
783 
783 


LIST   OF  ILLUSTRATIONS. 


FRACTURES. 

FIG. 

1.  Perforating  and  longitudinal  fracture 

2.  Impacted  extra-capsular  fracture  of  neck  of  femur 

3.  Union  of  fracture  -with  the  fragments  -nidely  separated 

4.  Fracture  united  "with  an  oblique  callus 

5.  Application  of  the  roller,  by  circular  and  reversed  turns 

6.  Many-tailed  bandage  .... 

7.  Application  of  the  many-tailed  bandage 

8.  Bandage  of  Scultetus  .... 

9.  "Wood  and  leather  splint        . 

10.  Starch  bandage  applied  for  a  broken  thigh  . 

11.  Seutiu's  pliers  ..... 

12.  Opening  the  apparatus  with  Seutin's  pliers 

13.  Apparatus  immobile,  applied  over  a  compound  fracture 

14.  Clavicle,  united  by  ligamentous  bands 

15.  Hudson's  splint,  imuuited  fracture  . 

16.  Physick's  first  case,  treated  by  seton — after  28  years 

17.  DiefiFenbach's  drill  for  ununited  fracture 

18.  Brainard's  perforator  for  ununited  fracture 

19.  Bone-drill       ...... 

20.  Gaillard's  instrument  for  ununited  fractures 

21.  Fergusson's  case  of  permanent  bending  without  fracture 

22.  Partial  fracture  of  the  femur  without  restoration  of  the  bone  to  its 

form  ....... 

23.  Partial  fracture  of  the  clavicle  without  spontaneous  restoration 

24.  Partial  fracture  after  union  is  consummated 

25.  Fracture  of  the  lower  jaw    . 

26.  Bean's  maxillary  articulator 

27.  Bean's  apparatus  for  broken  jaw,  applied   . 

28.  Gibson's  bandage  for  a  fractured  jaw 

29.  Barton's  bandage  for  a  fractured  jaw 

30.  Four-tailed  bandage  or  sling  for  the  lower  jaw 

31.  The  author's  apparatus  for  a  broken  jaw   . 

32.  Fracture  of  the  spinous  process 

33.  Fracture  of  the  vertebral  arches 

34.  Obhque  fracture  of  the  body  of  a  vertebra 

35.  Key's  case  of  fracture  of  the  first  lumbar  vertebra 

2 


natural 


PAGE 

28 
28 
41 
41 
46 
46 
47 
47 
51 
54 
55 
56 
57 
64 
67 
68 
69 
70 
70 
71 
75 

80 
80 
82 
109 
124 
125 
129 
129 
130 
131 
143 
145 
1.52 
154 


XVlll 


LIST    OF    ILLUSTRATIOXS. 


FIG. 

3G.  Wire  bed         ...•••• 

37.  Parker's  case  of  fracture  of  the  odontoid  process  of  the  axis 

38.  Development  of  sternum      .  .  .  •  • 

39.  Fracture  of  the  ribs,  with  lateral  union 

40.  Complete  oblique  fracture  of  the  clavicle     . 

41.  Fracture  of  the  clavicle  outside  of  the  trapezoid  ligament 

42.  Complete  oblique  fracture  of  the  clavicle  at  the  outer  end  of 

two-thirds  ....••• 

43.  Comminuted  fracture  of  the  clavicle  united 
4.  Velpeau's  dressing  for  fractured  clavicle     . 

45.  rigure-of-8  bandage,  for  a  fractured  clavicle 

46.  Moore's  apparatus  for  fractured  clavicle 

47.  Sayre's  apparatus  for  fractured  clavicle 

48.  Sayre's  apparatus  for  fractured  clavicle 

49.  Sayre's  apparatus  for  fractured  clavicle 

50.  Bartlett's  apparatus  for  fractured  clavicle   . 

51.  Fox's  apparatus  for  fractured  clavicle 
53.  The  author's  apparatus  for  fractured  clavicle 

53.  Fracture  of  angle  of  the  scapula      .... 

54.  Fractures  of  the  body  and  acromion  process  of  the  scapula 

55.  Comminuted  fracture  of  the  glenoid  cavity 

56.  Fracture  of  the  neck  of  the  scapula 

57.  Scapula  with  epiphyses         ..... 

58.  Fracture  of  the  coracoid  process      .... 

59.  Fracture  at  the  anatomical  neck  of  the  humerus    . 

60.  61.  Pope's  specimen  of  supposed  fracture  at  the  anatomical  necl 

humerus,  and  reversion  of  the  head — front  and  side  views 

62.  Humerus  with  epiphyses, 

63.  Fracture  of  surgical  neck  of  humerus 

64.  Welch's  arm  splint    . 

65.  Plan  of  author's  leather  arm  splint . 

66.  Leather  splint  closed  at  top  and  complete 

67.  Lonsdale's  apparatus  for  extension,  in  fractures  of  the  humerus 

68.  Martin's  extension  in  fractures  of  the  humerus 

69.  Clark's  extension  in  fractures  of  the  humerus 

70.  Fracture  of  the  humerus  at  the  base  of  the  condyles 

71.  Separation  of  lower  epiphyses  .... 

72.  Physick's  elbow  splint  ..... 

73.  Kirkbride's  elbow  splint       ..... 

74.  Rose's  arm  and  forearm  splint  .... 

75.  Welch's  arm  and  forearm  splint       .... 

76.  Bond's  elbow  splint  ...... 

77.  The  author's  elbow  splint     ..... 

78.  Fracture  at  the  base  of  the  condyles  of  the  humerus,  and  betw 

condyles      ...... 

79.  Fracture  of  internal  epicondyle  of  the  humerus     . 

80.  Fracture  of  external  epicondyle 

81.  Fracture  of  the  internal  condyle  of  the  humerus    . 

82.  Fracture  of  external  condyle 

83.  Mutter's  specimen  of  fracture  of  the  neck  of  the  radius 

84.  Fracture  of  head  of  radius    . 


the  inner 


i  of  the 


een  the 


PAGE 

160 
163 
167 
174 
180 
183 

184 
186 
189 
193 
196 
196 
197 
197 
198 
199 
201 
203 
204 
207 
207 
210 
212 
215 

218 
222 
224 
233 
233 
233 
237 
238 
239 
245 
246 
249 
250 
250 
250 
251 
253 

253 
256 
260 
261 
264 
268 
270 


LIST    OF    ILLUSTEATIOXS. 


XIX 


FIG. 

85.  Scott's  apparatus  for  fractures  of  tlie  foreami 

86.  Fracture  of  the  shaft  of  the  radius  .... 

87.  CoUes'  fracture — radius  near  its  lower  end 

88.  Bigelow's  case  of  comminuted  fracture  of  the  lower  end  of  the  radius 

89.  Nelaton's  splint  for  fracture  of  the  radius  near  its  lower  end 

90.  Bond's  splint  for  fracture  of  the  lower  end  of  the  radius 

91.  Ha)''s  splint  for  fracture  of  the  lower  end  of  the  radius  . 

92.  E.  P.  Smith's  splint  for  fractures  of  the  lower  end  of  the  radius — front 

view  ........ 

93.  Same  as  above — back  view  ..... 

94.  Shrady's  splint  for  CoUes'  fracture  .... 

95.  The  author's  splint  for  fracture  near  the  lower  end  of  the  radius 

96.  The  author's  dressing  for  a  fracture  of  the  radius  near  its  lower  end- 

complete    .  ....... 

97.  Radius,  with  epiphyses        ...... 

98.  Fracture  of  the  shaft  of  the  ulna    ..... 

99.  Fracture  of  the  coronoid  process  of  the  ulua 

100.  Ulna,  with  epiphyses  ...... 

101.  Fracture  of  the  olecranon  process  at  its  base 

102.  Olecranon  process  united  bj'  ligament        .... 

103.  Sir  Astley  Cooper's  method  of  dressing  a  fracture  of  tlie  olecranon 

process        ........ 

104.  The  author's  splint  for  a  fracture  of  the  olecranon  process,  applied 

105.  Fracture  of  the  radius  and  ulna  in  the  middle  third 

106.  Fracture  of  the  radius  and  ulna  in  the  lower  third 

107.  Radius  and  ulna  united  with  displacement 

108.  Development  of  os  inuominatum    ..... 

109.  Clark's  case  of  comminuted  fracture  of  the  pelvis 

110.  Development  of  femur         ...... 

111.  Fracture  of  the  neck  of  the  femur,  within  the  capsule    . 

112.  Impacted  fracture  of  the  neck  of  the  femur,  within  the  capsule  . 

113.  Horizontal  section  of  the  neck  of  the  femur 

114.  Extra-capsular  fracture  with  inversion       .... 

115.  Vertical  section  of  Mrs.  Wakelee's  femur,  acetabulum,  and  capsule 

116.  Impacted  fracture  within  the  capsule         .... 

117.  Section  of  the  head  and  neck  of  the  sound  femur  of  an  adult     . 

118.  Chronic  rheumatic  arthritis,  in  hip-joint 

119.  Crosby's  specimen  of  fracture  of  neck  of  femur  within  the  capsule — 

ununited      ........ 

120.  Mayo's  specimen  of  fracture  of  the  neck  of  the  femur  within  the  cap 

sule — united  by  ligament  ...... 

121.  Author's  apparatus  for  fractures  of  the  neck  of  the  femur 

122.  Gibson's  modification  of  Hagedorn's  thigh  splints  . 

123.  Gibson's  splint  applied         ...... 

124.  125,  126.  Impacted  extra-capsular  fracture 

127.  Fracture  of  the  neck  of  the  femur  .... 

128.  Extra-capsular  fracture  of  the  neck  of  the  femur — ununited 

129.  Extra-capsular  fracture  of  the  neck  of  the  femur — with  excess  of  callus 

130.  Extra-capsular  fracture  of  the  neck  of  the  femur — united  with  irregular 

callus  ......... 

131.  Miller's  splint  for  extra-capsular  fractures  .  .  .  .  . 


PAGE 

272 
273 

275 
279 

285 
285 
285 


381 
382 


XX 


LIST    OF    ILLUSTKATIONS. 


FIG. 

132.  Sir  Astlcy  Cooper's  mode  of  treating  fractures  of  the  troclianter  major 

133.  Fracture  of  the  femur  at  the  base  of  the  condyles 

134.  Physick's  thigh  sphut  ..... 

135.  Liston's  dressing  of  fractured  femur  with  a  straight  splint 

136.  Double-inclined  plane  in  Middlesex  Hospital,  London      . 

137.  Amesbury's  double-inclined  plane  .... 

138.  Amesbury's  splint  applied  ..... 

139.  Boyer's  thigh  splint  applied  .... 

140.  Nathan  R.  Smith's  suspending  thigh  splint,  or  double-inclined  plane 

141.  Nott's  double-inclined  plane 

142.  N.  R.  Smith's  anterior  splint 

143.  N.  R.  Smith's  anterior  splint,  applied 

144.  Palmer's  modification  of  the  anterior  splint 

145.  Hodgen's  suspension  apparatus 

146.  Neill's  straight  thigh  splint,  for  extension  and  counter-extension 

147.  Flagg's  thigh  apparatus — employed  in  the  Massachusetts  General  IIos 

pital.     Pelvic  belt  and  perineal  straps 

148.  Same — foot-piece  and  screw 

149.  Same — lateral  view  of  the  apparatus,  witliout  the  belt 

150.  Same — front  view,  with  folded  sheets  laid  across  . 

151.  Same — apparatus  applied,  front  view 

152.  Same — apparatus  applied,  side  view 

153.  Same — mode  of  applying  adhesive  plasters  to  leg 

154.  Same — mode  of  making  extension  by  adhesive  plasters 

155.  Same — perineal  band  secured  with  a  padlock 

156.  Sanborn's  thigh  splint 

157.  Gurdon  Buck's  fracture  apparatus  . 

158.  Horner's  thigh  splint 
152.  Joseph  Hartshorne's  thigh  splint    . 

160.  Gilbert's  extension  in  fracture  of  the  thigh 

161.  Gilbert's  extension  applied  to  both  thighs  . 

162.  H.  L.  Hodge's  counter-extension  in  fractures  of  the  thigh 

163.  Lente's  thigh  splint 

164.  Burge's  apparatus  for  fracture  of  femur    . 

165.  Burge's  apparatus  applied  . 

166.  Extension  during  application  of  plaster  of  Paris 

167.  Extension  continued  until  the  plaster  is  hard 

168.  Fracture  of  femur  just  below  trochanter  minor 

169.  Jenks'  fracture-bed 

170.  Daniels'  fracture-bed — descriptive  diagram 

171.  The  same — complete 

172.  The  same — in  use    .... 

173.  Crosby's  invalid-bed,  closed 

174.  Crosby's  invalid-bed,  open  . 

175.  Standard  for  extension 

176.  Foot-piece     ..... 

177.  Extension-band  and  foot-piece 

178.  Extension-band  and  foot-piece  folded 

179.  Mode  of  applying  adhesive  plaster  for  extension 

180.  Author's  dressings  for  fracture  of  shaft  of  femur,  complete 

181.  Author's  splint  for  fracture  of  femur  in  a  child     . 


PAGE 

385 
387 
395 
396 
398 
399 
399 
399 
400 
401 
401 
402 
402 
403 
404 

404 
404 
404 
404 
405 
405 
405 
405 
406 
406 
407 
407 
408 
408 
408 
409 
410 
410 
411 
413 
414 
415 
418 
419 
419 
420 
421 
421 
422 
428 
423 
423 
424 
425 
427 


LIST    OF    ILLUSTRATIONS. 


XXI 


FIG. 

183.  Author's  dressing  for  fracture  of  femur  in  a  child — complete 

183.  Crosby's  specimen  of  fracture  of  the  external  condyle  of  the  femur 

184.  Sir  Astley  Cooper's  case  of  fracture  of  the  external  condyle  of  the  femur 

185.  Transverse  fracture  of  the  patella  ..... 

186.  Comminuted  fracture  of  the  patella  .... 

187.  Transverse  fracture  of  the  patella — exhibiting  the  relations  of  the  mus 

cles  to  the  fracture  ...... 

188.  Fragments  of  a  broken  patella  sej^arated  by  flexion  of  the  knee 

189.  Upper  fragment  of  a  broken  patella  drawn  up  very  much  by  the  action 

of  the  quadriceps  femoris  ..... 

190.  The  author's  mode  of  dressing  a  fractured  patella 

191.  Wood's  apparatus  for  a  fractured  patella  .... 

192.  Dorsey's  imtella  splint         ...... 

193.  Sir  Astley  Cooper's  method  for  broken  patella  by  circular  and  parallel 

tapes  ........ 

194.  Sir  Astley  Cooper's  method  by  a  leather  band  and  counter-strap 

195.  Lonsdale's  apparatus  for  fractured  patella 

196.  Malgaigne's  hooks  for  fractured  patella     .... 

197.  Burge's  apparatus  for  fractured  patella      .... 

198.  Lausdale's  apparatus  for  fractured  patella  .  .  . 

199.  Development  of  tibia  ...... 

200.  Development  of  tibula         ...... 

•201.  Fracture  of  the  fibula  near  its  lower  end  .... 

203.  Dupuytreu's  splint  incorrectly  applied      .... 

203.  Dupuytren's  splint,  as  originally  made  and  applied  by  himself  . 

204.  Compound  and  comminuted  fracture  of  the  leg     . 

205.  Long  splint  for  fracture  of  the  leg  in  Pott's  position 

206.  Plaster  of  Paris  dressing  for  fracture  of  leg,  and  suspension 

207.  Hutchinson's  splint  for  extension  in  fractures  of  the  leg 

208.  Neill's  apparatus  for  fractures  of  the  leg  requiring  extension  and  coun 

ter-extensiou  .  .  •         . 

209.  Neill's  apparatus  for  compound  fractures  of  the  leg         .  .  . 

210.  Gilbert's  fracture-box  ...... 

211.  Crandall's  apparatus  for  fractures  of  the  leg  requiring  extension  and 

counter-extension — side  view       ..... 
213.  Same — posterior  view  of  the  lower  section 
213.  Same — posterior  view  of  the  entire  apparatus 
314.  Listen's  double-inclined  plane,  applied  to  the  leg  in  a  case  of  compound 

fracture       ........ 

215.  Bauer's  wire  splints,  for  the  leg     . 

316.  Swing  box,  for  fractures  of  the  leg  .... 

317.  Salter's  cradle  for  fractures  of  the  leg  .... 
218.  Fracture-box  for  the  leg,  with  movable  sides 
319.  Wire  rack,  for  fracture  of  the  leg  ..... 
230.  Malgaigne's  apparatus  for  certain  oblique  fractures  of  the  leg  . 
331.  IMalgaigne's  apparatus  applied  ..... 
323.  Apparatus  for  fracture  of  the  tuberosity  of  the  calcaneum 

223.  Author's  movable  canvas  for  gunshot  fractures  of  thigh 

224.  Author's  movable  canvas  for  gunshot  fractures  of  thigh,  Avith  extension, 

on  horses    ......••• 


PAGE 

437 
438 
439 
434 
434 

435 
435 

436 
439 

440 
440 

441 
443 
443 
443 
443 
444 
445 
449 
450 
453 
452 
455 
459 
466 
467 

467 
468 
468 

469 
469 
469 

471 
471 
473 
473 
473 
473 
473 
474 
480 
487 

487 


xxu 


LIST    OF    ILLUSTKATIONS. 


DISLOCATIONS, 


FIG. 
235. 
236. 

337, 
329. 
230. 
231. 
232. 
233. 
234. 
335. 
236, 
238. 
239. 
240. 
241. 
242. 
243. 
244. 
245. 
246. 
247. 
248. 
249. 
250. 
251. 
252. 
253. 
254. 
255. 
356. 

257. 
258. 
259. 
260, 
263. 
263. 
264. 
265. 
266. 

267, 
269. 

270. 

271. 

272. 


PAGE 
500 

500 

503,  504 

519 


Clove-hitch  ....••• 

Compound  pulleys  and  ring  .... 

338.  Double  dislocation  of  the  inferior  maxiHa     . 

Ayres'  case  of  bilateral  dislocation  of  the  fifth  cervical  vertebra 

Dislocation  of  the  sternal  end  of  the  clavicle,  forwards    . 

Sir  Astley  Cooper's  apparatus  for  dislocated  clavicle 

Dislocation  of  sternal  end  of  clavicle  upwards 

Dislocation  of  the  acromial  end  of  the  clavicle,  upwards 

Dislocation  of  acromial  end  of  clavicle  upAvards  and  outwards 

Mayor's  apparatus  for  dislocated  clavicle  . 

337.  Dislocation  of  the  shoulder  downwards  into  the  axilla        .  543, 

New  socket,  in  an  ancient  luxation  of  the  shoulder  downwards 

N.  R.  Smith's  method  of  reducing  a  dislocation  of  the  shoulder 

La  Mothe's  method  of  reducing  a  dislocation  of  the  shoulder — modified 

Sir  Astley  Cooper's  method,  with  the  heel  in  the  axilla  . 

Sir  Astley  Cooper's  method,  with  the  knee  in  the  axilla 

Iron  knob  employed  by  Skey,  instead  of  the  heel 

Skey's  method  in  dislocations  of  the  shoulder 

Sir  Astley  Cooper's  method,  by  means  of  pulleys 

Subcoracoid  dislocation  of  the  humerus     .... 

Subclavicular  dislocation  of  the  humerus  .... 

Subcoracoid  dislocation  of  the  humerus     .... 

Subspinous  dislocation  of  the  humerus       .... 

Displacement  of  the  long  head  of  the  biceps 

Dislocation  of  the  head  of  the  radius  forwards — anatomical  relations 

Dislocation  of  the  head  of  the  radius  forwards     . 

Dislocation  of  the  head  of  the  radius  backwards 

Dislocation  of  the  upper  end  of  the  ulna  backwards 

Dislocation  of  the  radius  and  ulna  backwards 

Sir  Astley  Cooper's  method  in  dislocation  of  the  radius  and  ulna  back 

wards  ........ 

Most  frequent  form  of  incomplete  outward  dislocation  of  the  forearm 
Most  frequent  form  of  incomplete  inward  dislocation  of  the  forearm 
Canton's  case,  dislocation  of  the  radius  and  ulna  forwards 
361.  Dislocation  of  the  carpal  bones  backwards    ... 
Dislocation  of  the  carpal  bones  forwards — skeleton 
Dislocation  of  the  carpal  bones  forwards  . 
Dislocation  of  the  first  phalanx  of  the  thumb  backwards 
Clove-hitch  ....... 

Sir  Astley  Cooper's  method  of  reducing  dislocations  of  the  thumb  by 

the  pulleys  ........ 

368.  Levis's  instrument  for  reduction  of  the  phalanges    .  .  625,636 

Indian  "  puzzle"— employed  in  the  reduction  of  dislocations  of  small 

joints 636 

Backward  dislocation  of  the  first  phalanx  of  the  index  finger— reduction 

by  extension  ........       639 

Dislocation  of  the  second  phalanx  backwards       .  .  .  .630 

Dislocation  of  the  second  phalanx  forwards  ....       631 


525 
527 
529 
533 
533 
536 
543 
549 
554 
555 
555 
556 
557 
557 
558 
567 
568. 
569 
574 
577 
580 
581 
586 
587 
589 

593 
598 
603 
605 
610 
611 
612 
020 
623 

633 


LIST    OF    ILLUSTKATIOXS. 


XXlll 


FIG. 
273. 
274. 
275. 

276. 

277. 
278. 

279. 

280. 
281. 
282. 
283. 
284. 

285. 

280, 


289. 
290. 

291. 
292. 
293. 

294. 
295. 

296. 

297. 

298. 

299. 
300. 
301. 
302. 
303. 
304, 
306. 
307. 
308. 
309. 
310. 
311. 
312, 
314. 
315. 
316. 


Dislocation  of  the  femur  upon  the  dorsum  ilii 

Ilio-femoral  ligament  .  .  .  .  . 

Dislocation  of  the  femur  upon  the  dorsum  ilii,  showing  relations  of  ilio 

femoral  ligament    ....... 

Dislocation  of  the  femur  upon  the  dorsum  ilii 

Everted  dorsal  dislocation  ....  .  . 

Nathan  Smith's  method  of  reduction  of  a  dislocation  of  the  head  of  the 

femur  upon  the  dorsum  ilii,  by  manipulation 
Relaxation  of  the  ilio-femoral  ligament,  by  flexion 
Hippocrates'  mode  of  reducing  dislocations  of  the  hip  by  manipulation 
Reduction  of  a  dislocation  upon  the  dorsum  ilii  by  pulleys 
Reduction  of  a  dislocation  upon  the  dorsum  ilii  by  a  twisted  rope 
Jarvis's  adjuster — applied  in  dislocation  of  the  hip 
Bloxham's  dislocation  tourniquet — applied  for  reduction  of  a  dislocation 

of  the  femur  upon  the  pubes         .... 
Bigelow's  tripod  for  vertical  extension 
287.  Dislocation  of  the  femur  upwards  and  backwards  into  the  great 

ischiatic  notch        ....... 

Internal  obturator  in  its  natural  position    .... 

Internal  obturator  in  its  new  position        .... 

Dislocation  upwards  and  backwards  into  the  great  ischiatic  notch 

"below  the  tendon,"  when  the  patient  is  recumbent     . 
Reduction  of  a  dislocation  into  the  great  ischiatic  notch,  by  pulleys 
Relations  of  the  ilio-femoral  ligament  to  thyroid  dislocations 
Dislocation  of  the  femur  downwards  and  forwards  into  the  foramen 

thyroideum  ...... 

Reduction  of  thyroid  dislocation  by  manipulation 

Sir  Astley  Cooper's  mode  of  reducing  recent  luxations  of  the  femur  into 

the  foramen  thyroideum    ..... 
Effect  of  flexion  upon  the  ilio-femoral  ligament  in  the  thyroid  disloca 

tion  ........ 

Specimen  of  dislocation  upon  the  pubes,  in  St.  Thomas's  Hospital 
Dislocation  upon  the  pubes  below  the  anterior  inferior  spine  of  the 

ilium  ....... 

Dislocation  upwards  and  forwards  upon  the  pubes 
Reduction  of  dislocation  upon  the  pubes  by  extension 
Anterior  oblique  dislocation  .... 

Mechanism  of  anterior  oblique  dislocation 
Supra-spinous  dislocation    ..... 

305.  Voluntary  subluxation  upon  the  dorsum  ilii  . 

Dislocation  of  the  patella  outwards 

Dislocation  of  the  patella  inwards 

Dislocation  of  the  head  of  the  tibia  backwards    . 

Dislocation  of  the  head  of  the  tibia  forwards 

Subluxation  of  the  head  of  the  tibia  outwards 

Subluxation  of  the  head  of  the  tibia  inwards 

313.  Dislocation  of  the  lower  end  of  the  tibia  inwards     .  .  714 

Reduction  of  a  dislocation  of  the  ankle  by  pulleys 

Dislocation  of  lower  end  of  the  tibia  outwards     . 

Partial  dislocation  of  the  tibia  forwards,  with  fractures  of  malleolus 

internus  and  fibula — skeleton       .  .  ... 


'AGE 

685 
637 

6.S8 
089 
640 

645 
647 
048 
649 
630 
651 

651 
660 

061 
062 
663 

663 
066 
609 

669 
671 

673 

673 
674 

670 
676 
078 
080 
681 
681 
695 
697 
699 
704 
706 
709 
710 
715 
716 
719 

721 


XXIV 


LIST    OF    ILLUSTEATIONS, 


FIG. 

317.  Partial  dislocation  of  the  tibia  forwards,  with  fracture  of  the  malleolus 

internus  and  fibula  .  .  .  .  • 

318,  319.  Dislocation  of  the  lower  end  of  the  tibia  backwards 

320.  Dislocation  of  the  astragalus  outwards— anatomical  relations 

321.  Simple  dislocation  of  the  astragalus  outwards 

322.  Compound  dislocation  of  the  astragalus  inwards  . 


PAGE 

721 
724 
728 
729 
729 


PART    I. 


FRACTURES 


PRAOTUEES. 


CHAPTER    I. 

GENERAL  DIVISION  OF  FRACTURES. 

Fractures  are  divided  into  Complete  and  Incomplete,  Simple, 
Comminuted,  Compound,  and  Complicated. 

A  Complete  fracture  is  one  in  which  the  line  of  division  completely 
traverses  the  bone. 

An  Incomplete  fracture  is  a  partial  separation  of  the  bone :  under 
which  name  are  included  Bending,  Partial  fractures,  Fissures  and 
Punctured  or  Perforating  fractures,  the  last  of  which  is  almost  pecu- 
liar to  gunshot  injuries. 

A  Simple  fracture  is  one  in  which  the  bone  is  broken  at  only  one 
point.  The  term  has  no  reference  to  the  question  of  complications, 
but  in  its  technical  meaning,  as  employed  by  both  English  and  Ameri- 
can surgeons,  it  has  reference  only  to  the  number  of  fragments  into 
which  the  bone  is  broken.  It  would  be  more  correct,  perhaps,  to  sub- 
stitute the  word  "single"  for  "simple,"  as  has  been  done  by  Malgaigne 
and  some  other  French  writers,  but  I  fear  that  to  American  surgeons 
the  substitution  would  be  rather  a  source  of  confusion  than  otherwise. 

A  Comminuted  fracture,  called  by  Malgaigne  "  multiple,"  is  a  frac- 
ture in  which  the  bone  is  broken  at  more  than  one  point,  and  in  which, 
consequently,  the  bone  is  divided  into  more  than  two  fragments.  It 
is  used  also  in  a  technical  sense,  and  by  no  means  implies  minute 
division  or  comminution  of  the  fragments. 

A  Compound  fracture  is  technically  one  in  which  there  exists  also 
an  external  wound  communicating  with  the  bone  at  the  point  of  frac- 
ture. It  may  be  either  partial  or  complete,  simple  or  comminuted,  or 
even  complicated,  while  at  the  same  time  it  is  also  compound. 

Complicated  fractures  are  such  as  present  additional  complications, 
or  complications  for  which  no  other  specific  term  has  been  invented. 
Thus,  the  fracture  may  be  complicated  with  the  lesion  of  an  important 
bloodvessel  or  nerve,  or  with  great  contusion  or  laceration  of  the  soft 
parts,  with  a  dislocation,  or  with  fractures  of  other  bones,  or  even 
with  some  constitutional  fault. 

Fractures  are  also  divided  into  Transverse,  Oblique,  and  Longitu- 
dinal, according  as  the  direction  of  the  line  of  separation  is  at  a  right 
angle  with  the  axis  of  the  bone  at  the  point  of  fracture,  or  as  it  deviates 


28 


GENERAL    DIVISION    OF    FRACTURES. 


more  or  less  from  this  direction.  But  a  fracture  is  called  transverse 
when  it  does  not  traverse  the  bone  precisely  at  a  right  angle ;  indeed, 
we  usually  apply  this  term  whenever  the  obliquity  is  only  moderate, 
or  when,  in  the  examination  of  a  limb,  although  we  are  unable  to 
detect  the  precise  line  of  the  fracture,  we  ascertain  that,  without  being 
impacted  or  serrated,  the  ends  of  the  bones  continue  to  rest  upon  each 
other,  or,  being  replaced,  do  not  spontaneously  become  displaced. 

Longitudinal  fractures  occur  generally  in  connection  with  oblique 
or  transverse  fractures;  as  when  the  lower  end  of  the  femur  is  split 
vertically  into  the  joint,  and  the  shaft  of  the  bone  is  traversed  hori- 
zontally by  a  fracture  which  intercepts  the  vertical  or  longitudinal 
fracture.  A  fracture  of  a  condyle  or  of  any  projection  from  the 
body  of  the  bone  is  called  longitudinal  if  the  direction  of  the  line  of 
fracture  is  parallel,  or  nearly  so,  to  the  axis  of  the  shaft. 


Fijsr.  1. 


Fiff.  3. 


Perforating  and  longitudinal  fracture. 


Impacted,  extra-capsular  fracture 
of  neck  of  femur. 


A  Serrated  fracture  is  one  in  which  the  opposite  surfaces  denticu- 
late, the  elevations  upon  one  fragment  being  reflected  by  corresponding 
depressions  upon  the  other. 

Impacted  fractures  are  those  in  which  the  fragments  are  driven  into 
each  other,  the  lamellated  structure  of  one  fragment  penetrating  the 
cancellous  structure  of  the  other. 

"Writers  also  occasionally  speak  of  fractures  en  rave,  en  hec  de  flute, 
en  hec  de  plume,  spiroid,  cuneate,  &c. ;  but  we  do  not  see  the  propriety 
of  multiplying  the  divisions  and  encumbering  our  nomenclature  by 
these  fancied  resemblances.  Tor  all  useful  purposes,  the  divisions 
above  given  are  sufficient. 

Epiphyseal  separations  we  shall  not  hesitate  to  class  with  fractures, 
and  to  submit  them  to  the  same  rules  of  nomenclature.  These  acci- 
dents rarely  occur  after  the  twentieth  year  of  life;  since  after  this 
period,  and  in  the  case  of  some  bones  at  a  much  earlier  period,  the 
epiphyses  are  united  to  the  diaphyses  by  bone. 


GENERAL    ETIOLOGY    OF    FRACTURES.  29 


CHAPTER    II. 

GENERAL  ETIOLOGY  OF  FRACTURES. 

The  causes  of  fracture  may  be  considered  as  predisposing  and 
exciting. 

Predisposing  Causes. — Partial  fractures,  with  bending  of  the  bones, 
are  most  frequent  in  infancy  and  childhood  ;  but  complete  fractures 
occur  most  often  during  manhood  ;  and  if  they  are  again  less  frequent 
in  old  age,  it  is  because  the  exciting  causes  are  less  operative,  since 
the  fragility  of  the  bones,  as  a  general  rule,  increases  with  age.  It 
will  be  noticed,  also,  that  somewhat  in  proportion  as  the  bone  is  more 
brittle,  its  fracture  will  be  more  nearly  transverse,  so  that  very  old 
persons  have  frequently  what  has  been  not  inaptly  termed  the  "  pipe- 
stem  fracture ;"  but  we  must  except  from  this  rule  fractures  occurring 
in  children,  which  are  also  not  unfrequently  transverse,  often  denticu- 
lated or  splintered,  and  but  rarely  oblique.  In  all  of  the  intermediate 
periods  of  life,  oblique  fractures  are  by  far  the  most  common. 
Females  are  less  liable  to  fractures  than  males,  except  in  old  age, 
when  the  law  seems,  in  general,  to  be  reversed.  As  to  the  season  of 
the  year,  it  has  been  generally  observed  by  surgical  writers  that 
fractures  were  more  frequent  in  winter  than  in  summer,  and  an 
explanation  has  been  sought  for  in  the  greater  rigidity  of  the  muscles 
during  the  cold  weather,  and  the  greater  liability  to  falls  upon  the  ice 
and  frozen  ground.  Some  have  affirmed  that  the  bones  themselves 
were  more  brittle ;  but,  aside  from  the  improbability  of  this  last 
explanation,  it  is  a  matter  of  question  whether  fractures  are  actually 
more  frequent  in  the  winter  than  in  the  summer.  If,  on  the  one 
hand,  the  rigidity  of  the  muscles  and  falls  upon  slippery  walks  are 
active  causes  in  the  production  of  fractures  in  the  one  season,  on  the 
other  hand,  falls  from  buildings  and  accidents  from  a  great  variety  of 
similar  causes  are  equally  active  agents  in  the  other. 

Mollities  ossium,  rickets,  cancer,  tertiary  lues,  scrofula,  gout,  scurvy, 
mercurialization,  and,  in  short,  all  diseases  dependent  upon  cachexias, 
more  or  less  predispose  to  the  occurrence  of  fractures.  Inflammation 
of  the  periosteum,  also,  or  of  the  bone  itself,  may  predispose  to  frac- 
ture. It  is  said,  moreover,  that  the  bones  of  persons  who  have  lain  a 
long  time  in  bed  break  easily. 

Exciting  Causes. — The  exciting,  determining,  or  immediate  causes  of 
fractures  are  of  two  kinds :  mechanical  violence  and  muscular  action. 

Of  these  two,  mechanical  or  external  violence  is  much  the  most 
frequent  cause  ;  and  this  violence  may  operate  in  two  ways:  by  acting 
directly  upon  the  bone  at  the  point  at  which  it  separates,  and  then  we 
say  the  fracture  is  "direct,"  or  from  "direct  violence;"  or  by  acting 
upon  some  point  remote  from  the  seat  of  fracture,  and  then  we  say  the 


80  GENERAL    ETIOLOGY    OF    FRACTURES. 

fracture  is  "indirect,"  or  from  a  "counter-stroke."  When  a  person 
falls  from  a  height,  alighting  upon  his  feet,  and  the  leg  or  thigh  is 
broken,  the  fracture  is  indirect ;  so  also  if  the  bone  is  broken  by  flexion 
or  torsion.  Even  direct  pressure  upon  one  side  of  a  long  bone  in  a 
child  may  produce  a  partial  fracture  upon  the  opposite  side,  which  is 
properly  an  indirect  fracture ;  or  a  direct  blow  upon  the  trochanter 
major  may  occasion  a  counter- fracture  through  the  neck  of  the  femur. 

Fractures  from  muscular  action  occur  most  often  in  the  patella, 
calcaneum,  humerus,  femur,  tibia,  and  olecranon  process  of  the  ulna. 
These  accidents  imply  generally  some  conditions  of  the  bones  them- 
selves which  predispose  them  to  fracture ;  but  I  have  seen  one  example 
of  a  fracture  of  the  shaft  of  the  femur  in  a  large  and  perfectly  healthy 
man,  occasioned  by  a  twist  of  the  leg  in  rolling  tenpins.  I  have  also 
known  the  tibia  and  patella  to  break  from  natural  muscular  action  in 
persons  of  uncommon  vigor.  Fractures  sometimes  occur  in  the  violent 
contractions  of  the  muscles  during  convulsions,  and  where  no  abnormal 
condition  of  the  bones  could  be  assumed  to  exist.  Parker,  of  New 
York,  relates  a  case  of  fracture  of  the  humerus  in  a  negro  preacher, 
which  occurred  in  the  act  of  gesticulation ;  also,  a  fracture  of  the 
clavicle  occasioned  by  striking  a  dog  with  a  whip ;  in  another  case 
the  humerus  was  broken  in  attempting  to  throw  a  peach  ;  but  the  most 
singular  case  of  all  was  a  fracture  of  the  humerus  caused  by  an  effort 
to  extract  a  tooth. ' 

Lente,  of  New  York,  has  seen  both  femurs  broken  in  epileptic 
convulsions,  in  a  child  twelve  years  of  age.  The  left  femur  was  broken 
April  10th,  1859,  at  the  junction  of  the  upper  with  the  middle  third, 
and  the  right  femur  was  broken  at  the  same  point  eight  months  after, 
and  about  six  weeks  later  he  died.  The  first  fracture  united  with 
eonsiderable  bowing  and  shortening.  The  second  did  not  unite  at  all. 
He  had  been  subject  to  epilepsy  since  he  was  fifteen  months  old.^ 

Eemarkable  examples  of  fragility  of  the  bones  have  been  from  time 
to  time  recorded.  Gibson  relates  the  case  of  a  young  man  who  at 
the  age  of  nineteen  had  suffered  twenty-four  fractures.  Arnott  speaks 
of  a  girl  who  at  the  age  of  fourteen  had  suffered  thirty-one  fractures; 
Esquirol  had  in  his  possession  the  skeleton  of  a  woman  in  which 
were  found  traces  of  more  than  two  hundred  fractures;  and  we  have 
had,  at  the  Charity  Hospital,  a  man  ast.  53,  who  had  suffered  eleven 
fractures  and  two  dislocations,  in  whose  case  both  the  susceptibility 
to  fractures  and  to  dislocations  appeared  to  be  hereditary.^  In  most 
of  these  cases,  so  far  as  is  known,  union  occurred  rapidly. 

Nearly  all  of  the  cases  of  fractures  occasioned  by  muscular  contrac- 
tion seen  by  me  were  transverse,  or  nearly  so,  indicating,  perhaps, 
also  the  existence  of  some  unusual  fragility ;  and  most  of  these  have 
been  unattended  with  shortening,  the  ends  of  the  bones  not  becoming 
completely  displaced  from  each  other.     The  example  of  fracture  of 

'  Parker,  New  York  Journ.  Med.,  July,  1852,  p.  95. 

2  Am.  Med.  Times  and  Advertiser,  July  21,  1860,  p.  41. 

3  The  Physician  and  Pharmaceutist,  Feb.  1870.  Report  by  Armenag  Assadoorian, 
House  Surgeon. 


GENERAL    ETIOLOGY    OF    FRACTURES.  81 

the  shaft  of  the  femur  just  mentioned,  as  having  been  broken  in  rolling 
tenpins,  was,  however,  an  exception.  The  bone  shortened  to  the  ex- 
tent of  an  inch  or  more,  in  consequence  of  overlapping,  and  in  this 
position  it  has  finally  united, 

Intra-uterine  fractures  are  not  yet  fully  explained,  but  it  is  probable 
that  they,  like  extra-uterine  fractures,  may  be  ascribed  sometimes  to 
external  violence,  and  at  other  times  to  simple  muscular  contraction, 
both  perhaps  acting  upon  bones  already  somewhat  predisposed  by  a 
peculiar  constitutional  cachexy, 

Lawrence  Proudfoot,  of  New  York,  has  related  a  case  of  compound 
fracture  in  utero  occurring  in  the  practice  of  Dr.  Freeman,  which  was 
apparently  caused  by  external  violence.  Mrs,  F.,  get,  38,  always 
having  enjoyed  good  health,  during  the  sixth  month  of  gestation, 
while  attempting  to  pass  through  a  very  narrow  passage,  was  severely 
pressed  upon  the  abdomen,  and  immediately  experienced  a  severe  pain 
in  that  region,  accompanied  with  nausea  and  faintness.  The  following 
day,  uterine  hemorrhage,  with  pain,  commenced  ;  and  these  symptoms 
continued  at  intervals,  in  a  form  more  or  less  severe,  up  to  the  period 
of  her  delivery,  which  occurred  at  full  time,  and  was  perfectly  natural. 
At  birth,  the  right  foot  of  the  child,  a  female,  was  found  to  be  much 
distorted,  and  in  a  condition  of  valgus  with  equinus,  the  outer  side  of 
the  foot  being  laid  against  the  side  of  the  leg  above  the  external  mal- 
leolus. The  tibia,  also,  of  the  same  limb,  near  its  middle,  seemed  to 
have  been  the  seat  of  a  compound  fracture ;  the  two  ends  of  the  bone 
having  united  at  an  angle  slightly  salient  anteriorly,  and  the  skin 
presenting  over  the  point  of  fracture  an  old  cicatrix.  The  soft  tissues 
adjacent  were  considerably  thickened.  Seventeen  months  after  birth, 
when  the  child  was  seen  by  Drs,  Proudfoot,  Van  Buren,  and  Isaacs, 
the  foot,  although  much  improved  by  the  means  employed  by  Dr, 
Freeman,  was  still  considerably  deformed,  in  consequence  of  the  con- 
traction of  the  tendo-Achillis ;  on  cutting  which,  the  limb  was  found 
to  be  of  the  same  length  with  the  other.^ 

Dr,  Aristide  Rodrigue,  of  Hollidaysburg,  Pa,,  has  communicated  a 
case  of  fracture  with  dislocation,  which  he  ascribes  to  a  similar  cause. 
The  woman,  when  about  four  months  with  child,  fell  on  her  left  side, 
striking  upon  a  board,  and  hurting  herself  severely.  At  the  full  period 
she  was  delivered  of  a  well-grown  male  child.  Its  left  humerus  was 
found  to  be  dislocated  into  the  axilla,  and  both  the  radius  and  ulna  of 
the  same  limb  had  been  broken  through  their  lower  thirds,  but  were 
now  united  by  bony  callus  at  an  angle  of  about  45°,  and  slightly 
overlapped.  In  all  other  respects  the  child  was  perfect.  It  does  not 
appear  that  anything  was  done  to  the  fracture,  and  the  attempt  to 
reduce  the  humerus  was  unsuccessful.  Four  years  later  Dr,  R.  saw 
the  lad,  and  found  him  strong  and  hearty,  the  dislocated  humerus 
having  grown  nearly  at  the  same  rate  with  the  opposite,  but  the 
forearm  remained  "  short  and  deformed  as  at  birth,"  The  hand  was 
of  the  same  size  as  the  hand  of  the  sound  limb.^ 

'  Proudfoot,  New  York  Jonrn,  Med.,  Sept.  1846,  p.  199, 
*  Rodrigue,  Amer,  Jouru,  Med,  Sci.,  Jan,  1854,  p,  273, 


32  GENERAL    ETIOLOGY    OF    FRACTURES. 

Devergie  has  given  an  account  of  a  woman,  who,  when  seven 
months  with  child,  struck  her  abdomen  against  the  corner  of  a  table. 
Intense  pain  followed,  lasting  some  time.  She  went  her  full  period, 
however,  and  the  child  was  then  found  to  have  a  fracture  of  the  left 
clavicle,  the  fragments  being  overlapped  somewhat,  and  united  in 
this  position  by  a  firm  and  large  callus.'  A  woman  also  six  months 
gone  met  with  a  similar  accident,  and  at  the  full  time  she  gave  birth 
to  a  feeble  child,  having  in  one  leg  a  separation  of  the  shaft  of  the 
tibia  from  its  lower  epiphysis.  The  end  of  the  shaft  was  necrosed, 
and  projected  through  a  wound  in  the  integument.  This  child  died 
on  the  thirteenth  day.^ 

Schubert  reports  the  case  of  a  female  delivered  before  her  term,  of 
twins,  one  of  whom  was  born  with  a  fracture  of  the  left  thigh,  which 
had  occurred  in  utero ;  the  fractured  bone  had  pierced  the  flesh, 
through  which  it  projected  more  than  an  inch,  and  it  was  carious. 
The  mother  stated  that  about  six  weeks  before  the  accouchement, 
during  a  movement  of  the  foetus,  she  had  heard  a  noise  like  that 
produced  by  breaking  a  stick,  and  from  that  moment  she  had  felt 
pricking  pains  in  her  belly .^  It  is  probable  that  in  this  instance  the 
fracture  was  the  result  of  a  muscular  action,  although  it  is  possible 
that  it  was  occasioned  by  the  thigh  having  become  entangled  between 
the  legs  of  the  twin.  Similar  cases  have  been  recorded  by  Ploucquet, 
Kopp,  Devergie,  Cams,  Schubert,  Sachse,  Moffat,  and  Brodhurst." 

In  many  other  examples  upon  record^  the  explanation  is  plainly 
enough  to  be  sought  for  in  the  abnormal  or  rachitic  condition  of  the 
bones.  Monteggia  saw,  in  a  newly  born  infant,  twelve  ununited  frac- 
tures. Chaussier,  who  has  published  a  memoir  upon  this  subject, 
mentions  two  very  extraordinary  cases,  in  one  of  which  the  child  pre- 
sented forty-three  fractures,  and  in  the  other,  one  hundred  and  twelve.^ 
I  myself  was  permitted  to  see,  on  the  29th  of  June,  1853,  with  Drs. 
Hawley  and  White,  of  Buffalo,  an  infant  only  four  days  old,  who  was 
born  at  the  full  time,  of  a  healthy  mother,  in  whom  nearly  all  of  the 
long  bones  were  separated  and  movable  at  their  epiphyses,  the  motion 
being  generally  accompanied  with  a  distinct  crepitus.  The  bones 
were  also  much  enlarged  in  their  circumference;  the  bones  of  the 
forearm  and  the  femur  were  greatly  curved  ;  the  fontanelles  unusually 
open,  and  the  clavicles  were  entirely  wanting.  The  child  was  of  full 
size,  but  looked  feeble.  It  died  in  a  condition  of  marasmus  six  months 
after  birth ;  at  which  time  some  degree  of  union  had  taken  place  at 
several  of  the  points  of  separation,  the  limbs  having  been  supported 
constantly  with  pasteboard  splints  and  rollers. 

I  have  also  seen  one  example  of  complete  separation  of  the  tibia 
and  fibula  near  the  middle  of  the  leg,  which  I  was  disposed  to  regard 
as  defective  development,  rather  than  as  an  instance  of  intra-uterine 

'  Devergie,  Rev.  Med.,  1825. 

2  Malgaigne,  from  Archiv.  Gen.  de  Med.,  t.  xvi  p  288 

3  Amer.  Journ  Med.  Sci.,  May,  1828,  p.  223  ;  from  Zeitsch.  fiir  Staatsarz.  von 
Henkc,  7e  Erg.  Heft.,  p.  311.     Holmes'  Surgery,  voL  iv.  p   826 

I  Holmes'  Surgery,  vol.  iv.  827,  from  Med.-Chir.  Trans.,  vol.  xliii.,  1860,  art.  8. 
Lond.  Med.  Times  and  Gaz.,  April  7, 1860.  New  Orleans  Med  Journ.,  Nov.  1860. 
6  Cliaussier,  Bullet,  de  la  Faculte  de  Med.  de  Paris,  1813,  p.  301. 


GENERAL    SEMEIOLOGY    AND    DIAGNOSIS.  83 

fracture ;  and  a  gentleman  in  Michigan  has  sent  me  an  account  of 
another,  which  I  am  inclined  to  think  belongs  to  the  same  class  of 
deformities,  although  he  thought  it  might  be  a  case  of  intra- uterine 
fracture. 

Fractures  occurring  from  violence  inflicted  upon  the  child  by  the 
accoucheur,  or  from  contractions  of  the  neck  of  the  womb  while  the 
child  is  in  transitu,  are  more  common  occurrences,  and  do  not  require 
a  separate  consideration.  I  shall  mention  several  in  connection  with 
the  various  bones  in  which  they  have  taken  place ;  among  which,  one 
of  the  most  interesting  is  that  published  by  Jacob  H.  Vanderveer, 
of  Long  Branch,  N.  J.  The  mother  came  to  bed  on  the  18th  of 
January,  1847,  after  a  labor  of  more  than  twelve  hours.  It  was  a  foot 
presentation ;  the  child  weighed  fourteen  pounds,  and  was  perfectly 
healthy,  but  one  of  the  thighs  had  suffered  a  complete  fracture,  occa- 
sioned probably  by  the  strong  contractions  of  the  cervix  uteri.  With 
careful  splinting  and  bandaging,  the  bone  was  finally,  but  not  without 
some  difficulty,  kept  in  position  and  made  to  unite,  so  that  at  the  date 
of  the  report  one  would  not  discover  that  the  bone  had  been  broken, 
except  by  close  inspection.' 


CHAPTER    III. 

GENERAL  SEMEIOLOGY  AND  DIAGNOSIS. 

Fractures  are  liable  to  be  confounded  with  contusions,  and  with 
various  other  local  injuries,  but  most  often  with  dislocations ;  and 
especially  when  the  fracture  has  taken  place  near  one  of  the  articu- 
lations, is  the  differential  diagnosis  sometimes  rendered  exceedingly 
difi&cult.  It  is  with  particular  reference,  therefore,  to  the  general 
points  of  distinction  between  fractures  and  dislocations,  that  I  now 
propose  to  speak.  The  special  signs  or  points  of  difference  which 
belong  to  each  individual  case  will  be  considered  in  their  proper 
places. 

The  most  important  general  or  common  signs  of  a  fracture — and  by 
"common"  signs  I  mean  those  which  are  common  to  most  fractures — 
are  crepitus,  mobility,  and  an  inability  on  the  part  of  the  fragments 
to  maintain  their  positions  when  reduced  ;  indeed,  in  many  cases,  this 
constantly  recurring  displacement  is  due  to  the  fact  that  the  surgeon 
is  unable  to  accomplish  a  complete  reduction.  While,  on  the  other 
hand,  dislocations  are  almost  as  uniformly  characterized  by  the  absence 
of  crepitus,  by  preternatural  immobility,  and  by  the  fact  that,  when 
reduced,  the  bones  do  not  usually  require  support  to  retain  them  in 
place,  or  indeed,  we  may  say,  by  the  fact  that  they  are  generally 
reducible. 

'  Vanderveer,  Amer.  Journ.  Med.  Sci.,  May,  1847,  p.  378. 


34  GENERAL    SEMEIOLOGY    AND    DIAGNOSIS. 

Let  us  study  these  phenomena  a  little  more  in  detail. 

Crepitus,  occasioned  by  the  chafing  of  the  broken  surfaces  upon 
each  other,  when  actually  present,  is  almost  positive  evidence  of  the 
existence  of  a  fracture.  It  is  possible,  however,  to  confound  the  chaf- 
ing of  engorged  tendinous  sheaths,  or  of  inflamed  joints  upon  which 
fibrinous  effusions  have  occurred,  or  of  emphysema  even,  for  the  true 
crepitus  of  a  fracture ;  but  to  the  experienced  ear  and  well-practised 
touch  these  sensations  are  seldom  a  source  of  error.  The  one  is  rough, 
crackling,  or  even  clicking  sometimes,  while  the  other  is  more  sub- 
dued, and  imparts  a  more  uniform  sensation  to  the  hand,  and  but 
rarely  conveys  an  actual  sound,  unless  the  ear  is  directly  applied  or 
the  stethoscope  is  employed.  It  is  only  when  the  crepitus  is  trans- 
mitted obscurely  through  a  great  mass  of  soft  tissues,  or  sufficient 
time  has  elapsed  for  the  ends  of  the  fragments  to  become  softened  by 
inflammation  and  partially  covered  with  a  plastic  material,  or  when, 
indeed,  a  dislocation  is  actually  coincident  with  the  fracture,  that  the 
surgeon  is  left  in  doubt.  Occasionally,  also,  the  existence  of  caries  or 
of  necrosis,  in  connection  with  a  dislocation,  might  lead  to  the  sup- 
position of  a  fracture ;  but  the  history  of  the  case,  aside  from  the 
remaining  common  signs,  and  the  special  symptoms  hereafter  to  be 
enumerated,  would  prevent  any  possibility  of  error.  In  a  few  cases 
the  diagnosis  may  be  facilitated  by  the  application  of  the  ear  or  of  the 
stethoscope,  as  first  recommended  by  Lisfranc' 

It  must  not  be  forgotten,  moreover,  that  a  fracture  at  one  point 
may  transmit  the  sensation  of  crepitus  distinctly  enough,  but  in  such 
a  direction,  owing  to  the  relations  of  other  bones  to  the  one  broken, 
as  to  mislead  the  surgeon,  and  induce  him  to  locate  the  fracture  in  the 
wrong  bone.  Several  examples  of  this  species  of  deception  I  shall 
hereafter  have  occasion  to  mention. 

Valuable  and  important  as  is  crepitus  in  its  relations  to  differential 
diagnosis,  unfortunately  it  is  not  always  present,  and  for  reasons 
which  must  be  plainly  stated.  First :  we  cannot,  in  a  pretty  large 
proportion  of  cases,  bring  tire  broken  ends  again  into  apposition. 
Whatever  mere  theorists  may  say  to  the  contrary,  and  notwithstand- 
ing surgeons  up  to  this  time  have  rarely  ventured  to  allude  to  this 
subject,  the  fact  is  that  we  do  not  usually  "  set"  broken  bones.  We 
do  not,  even  at  the  first,  bring  them  into  complete  apposition,  unless  it 
is  as  the  exception.  I  speak  of  bones  once  completely  displaced  by 
overlapping,  and  these  constitute  the  majority  of  examples  which 
come  under  the  surgeon's  observation.  Second :  in  transverse  frac- 
tures of  the  patella,  and  in  fractures  of  the  olecranon  process  of  the 
ulna,  of  the  coracoid  and  acromion  processes  of  the  scapula,  and  in  all 
similar  detachments  of  processes  and  apophyses,  the  action  of  tbe 
muscles,  by  displacing  the  fragments,  may  prevent  crepitus  from 
being  readily  produced.  Third  :  in  a  few  cases,  such  as  certain  frac- 
tures of  the  neck  of  the  femur,  of  the  neck  and  head  of  the  humerus, 
&c.,  the  broken  ends  are  impacted,  or  so  driven  into  each  other  as  to 
forbid  the  production  of  motion  and  crepitus  ;  or  they  may  be  simply 

•  New  England  Med.  Journ.,  1824,  p.  220. 


GENERAL    SEMEIOLOGY    AND    DIAGNOSIS.  85 

denticulated,  and  the  consequences,  so  far  as  crepitus  is  concerned, 
will  be  the  same. 

Finally,  in  very  many  incomplete  fractures,  crepitus  does  not  exist; 
and  even  when  it  is  present,  the  sensation  is  feeble,  or  very  much 
modified,  sometimes  resembling  the  chafing  of  lymph,  and  at  other 
times  giving  only  a  faint  and  single  click.  Under  the  head  of  crepitus 
we  may  properly  include  the  sharp  crack  sometimes  felt,  or  even 
heard,  by  the  patient  at  the  moment  of  fracture. 

Preternatural  mobility,  less  valuable  as  a  means  of  diagnosis  than 
crepitus,  is,  nevertheless,  more  constantly  present,  being  never  absent, 
in  some  degree,  in  all  complete,  non-impacted,  and  non-denticulated 
fractures ;  but  its  presence  does  not,  like  crepitus,  render  the  existence 
of  a  fracture  quite  certain.  Whenever  the  bony  lesion  takes  place  in 
the  vicinity  of  a  joint,  it  may  be  difficult  or  impossible  to  determine 
whether  the  mobility  of  the  limb  is  due  to  motion  in  the  joint  or  to 
motion  at  the  supposed  seat  of  fracture.  While,  on  the  other  hand, 
the  preternatural  immobility  so  generally  observed  in  dislocations 
may  give  place  to  preternatural  mobility,  as  when  the  ligaments  and 
tendons  surrounding  the  joint  are  extensively  torn,  or  the  system  itself 
is  laboring  under  the  shock  of  the  accident,  or  when  from  any  other 
cause  there  exists  great  general  prostration. 

As  to  the  third  common  sign  mentioned,  namely,  that  in  the  case 
of  fractures  the  bones  do  not  generally  support  themselves,  but  de- 
mand for  this  purpose  the  interposition  of  splints,  bandages,  and  even 
of  extending  and  counter-extending  forces,  its  authority  rests  upon 
the  same  evidence  as  does  the  assertion  already  made  that  bones  once 
separated  entirely,  cannot  generally  be  "  set,"  that  is,  placed  again  end 
to  end  in  such  a  manner  as  to  be  made  effectually  to  support  each 
other.  It  rests  upon  the  evidence  of  my  own  personal  experience  ;  to 
which  I  am  permitted  to  add,  also,  the  personal  experience  of  Mal- 
gaigne,  who,  with  a  frankness  which  does  him  great  credit,  and  which, 
I  am  sorry  to  say,  has  hitherto  found  few  imitators,  remarks :  "  Second, 
That  overlapping  is  the  most  stubborn  of  all.  Here  I  will  add  a  dis- 
agreeable truth,  which  classical  authors  have  kept  too  much  out  of 
sight,  namely,  that  it  is  so  stubborn  that  in  an  immense  majority  of 
cases  the  efforts  of  art  are  unable  to  overcome  it."^  And  it  must  be 
observed  further,  that  if  we  shall  often  find  it  possible  to  bring  the 
broken  surfaces  sufficiently  into  contact  to  develop  crepitus,  they  may 
still  be  unable  to  maintain  themselves  in  this  position,  owing  to  the 
obliquity  of  the  line  of  fracture. 

The  other  common  signs  of  fracture  may  be  briefly  stated.  Pain 
at  the  seat  of  fracture ;  swelling;  ecchymosis;  deformity,  produced 
by  either  an  angular,  transverse,  or  rotatory  displacement  of  the  frag- 
ments, and  which  is  quite  as  often  due  to  the  direction  and  force  of 
the  impulse  which  occasioned  the  fracture  as  to  the  action  of  the  mus- 
cles; separation  of  the  fragments,  as  in  fractures  of  the  patella  and 
olecranon  process;  and  inability  to  move  the  limb,  a  phenomenon  due 
in  part  to  the  breaking  of  the  bony  lever  upon  which  the  muscles 

'  Malgaigne,  Traite  des  Fractures  et  des  Luxations,  Paris  ed.,  t.  i.  p.  102. 


86  GENERAL    SEMEIOLOGY    AND    DIAGNOSIS. 

acted,  and  in  part  to  the  intense  pain  caused  bj  any  sucH  attempts. 
This  latter  symptom  is,  however,  often  entirely  absent.  It  is  not 
generally  present  in  impacted  fractures,  in  serrated  and  partial  frac- 
tures, or  in  many  other  fractures  in  which  the  periosteum  has  not  yet 
completely  given  way. 

Yelpeau  was  the  first,  I  think,  to  call  attention  to  the  fact  that 
patients  with  broken  clavicles  could  very  generally  raise  the  arm 
above  the  shoulder  and  even  to  the  head,  and  I  have  repeatedly  veri- 
fied the  observation,  notwithstanding  the  separation  of  the  fragments 
has  been  complete,  and  the  overlapping  considerable.  In  fractures  of 
the  neck  of  the  femur  and  of  the  tibia  it  is  no  uncommon  thing  for  the 
patient  to  walk  some  distance  after  the  receipt  of  the  injury. 

As  has  been  previously  stated,  fractures  of  long  bones,  caused  by 
muscular  action,  generally  occur  near  the  middle  of  the  shaft,  and 
they  are  usually  transverse.  Direct  fractures  are  also  more  nearly 
transverse  than  indirect  fractures,  but  less  so  than  those  caused  by 
muscular  action;  while  those  indirect  fractures  which  are  caused  by 
a  force  applied  in  the  direction  of  the  axis  of  the  bone  are,  in  general, 
very  oblique.  But  what  is  of  more  importance  in  connection  with 
diagnosis  is,  that  in  this  latter  class  of  cases  the  fracture  usually  takes 
place  near  the  point  upon  which  the  force  of  the  blow  is  received 
Thus,  for  example,  a  fall  upon  the  hand  generally  causes  a  fracture  of 
the  lower  end  of  the  radius — a  Colles  fracture — or  if  both  bones  break, 
it  is  generally  below  the  middle,  and  very  seldom  indeed  in  the 
upper  third.  A  fracture  of  the  shaft  of  the  humerus  near  the  con- 
dyles is  a  frequent  result  of  a  fall  upon  the  elbow.  The  classical 
fracture  of  the  clavicle,  at  the  junction  of  the  middle  and  outer  thirds, 
is  usually  caused  by  a  fall  upon  the  shoulder.  A  fall  upon  the  foot 
causes  a  fracture,  in  most  cases,  near  the  lower  end  of  the  tibia,  and 
the  same  is  true,  quite  often,  of  the  lower  end  of  the  femur.  Exceptions 
to  the  rule  above  stated  are  most  commonly  met  with  in  advanced 
life,  when  falls  upon  the  elbow  occasion  fractures  at  the  surgical  neck 
of  the  humerus,  and  falls  upon  the  shoulder  sometimes  cause  frac- 
tures near  the  sternal  end  of  the  clavicle.  Similar  accidents  also  break 
the  tibia  near  its  upper  extremity,  and  the  femur  within  its  capsule. 
_  I  cannot  dismiss  this  subject  without  calling  attention  to  the  neces- 
sity of  exercising  care  and  gentleness  as  well  as  skill  in  the  examina- 
tion of  broken  limbs.  Nothing,  in  my  opinion,  betrays  a  lack  of 
judgment  as  well  as  of  common  humanity,  on  the  part  of  the  surgeon, 
so  much  as  a  rude  and  reckless  handling  of  a  limb  already  pricked 
and  goaded  into  spasms  by  the  sharp  points  of  a  broken  bone.  It  is 
not  enough  to  say  that  such  rough  manipulation  is  generally  unneces- 
sary, it  is  positively  mischievous,  provoking  the  muscles  to  more 
violent  contractions,  increasing  the  displacement  which  already  exists, 
and  sometimes  producing  a  complete  separation  of  the  impacted,  den- 
ticulated, transverse,  or  partial  fractures,  which  can  never  afterwards 
be  wholly  remedied  ;  augmenting  the  pain  and  inflammation,  and  not 
unfrequently,  I  have  no  doubt,  determining  the  occurrence  of  suppu- 
ration, gangrene,  and  death. 

In  proceeding  to  establish  the  diagnosis  in  any  case,  the  surgeon 


GENEKAL    SEMEIOLOGY    AND    DIAGNOSIS.  37 

should  sit  down  quietly  and  patiently  by  the  sufferer,  so  as  to  inspire 
in  him  from  the  first  a  confidence  that  he  is  not  to  be  hurt,  at  least 
unnecessarily.  He  ought  then  to  inquire  of  him  minutely  as  to  all 
the  circumstances  immediately  relating  to  the  accident,  in  order  that 
he  may  determine  as  nearly  as  possible  its  cause,  which  alone,  to  the 
experienced  surgeon,  often  affords  presumptive,  if  not  conclusive,  evi- 
dence as  to  the  nature  and  precise  point  of  the  injury.  From  this,  he 
should  proceed  to  examine  the  disabled  limb ;  removing  the  clothes 
with  the  utmost  care  by  cutting  them  away  rather  than  by  pulling; 
and  when  completely  exposed,  he  should  notice  with  his  eye  its  posi- 
tion, its  contour,  the  points  of  abrasion,  discoloration,  or  of  swelling; 
and  not  until  he  has  exhausted  all  these  sources  of  information,  ought 
the  surgeon  to  resort  to  the  harsher  means  of  touch  and  manipulation. 
Nor  will  his  sensations  guide  him  to  the  point  of  fracture  by  any  other 
method  so  accurately  as  when,  the  patient  being  composed  and  his 
muscles  at  rest,  he  moves  his  fingers  lightly  along  the  surface  of  the 
limb,  pressing  here  and  there  a  little  more  firmly,  according  as  a  trifling 
indentation  or  elevation  may  lead  him  to  suspect  this  or  that  to  be  the 
point  of  fracture. 

The  limb,  in  case  of  a  supposed  fracture  of  a  long  bone,  may  now 
be  measured  with  a  tape-line,  and  compared  with  the  opposite  limb, 
having  first  marked  with  a  soft  pencil  or  with  ink  the  several  points 
from  which  the  measurements  are  to  be  made. 

Finally,  if  any  doubt  remains,  the  limb  must  be  firmly  but  steadily 
held  while  the  necessary  manipulations  are  performed,  for  the  purpose 
of  ascertaining  the  existence  of  mobility  and  of  crepitus.  Mobility  is 
most  easily  determined  by  giving  to  the  limb  a  lateral  motion,  but,  in 
general,  crepitus  is  most  effectually  developed  by  gentle  rotation.  If 
the  place  of  fracture  is  already  pretty  well  declared  by  the  previous 
examinations,  the  surgeon  should  place  one  finger  over  the  suspected 
point,  during  this  manipulation,  by  which  means  the  crepitus  will  be 
more  certainly  recognized. 

I  do  not  often  find  it  necessary  to  resort  to  anaesthetics  for  the  pur- 
pose of  insuring  quietude  and  annihilating  pain  in  making  these 
examinations,  since  it  is  seldom  that  the  patient  need  to  be  much  dis- 
turbed; but  if  the  examination  is  not  satisfactory,  and  the  diagnosis 
is  important,  I  do  not  hesitate  to  render  the  patient  completely  insen- 
sible, after  which  the  questions  in  doubt  may  be  more  thoroughly 
investigated  and  perhaps  definitely  settled. 

The  surgeon  ought  not  to  forget,  however,  that  while  the  patient  is 
under  the  influence  of  an  anaesthetic,  violent  manipulations  are  no  less 
liable  to  rupture  bloodvessels,  and  to  lacerate  other  tissues,  than  if 
employed  when  the  patient  is  conscious.  Surgeons  have  not  seemed 
always  to  understand  this,  and  the  result  has  been  that  in  too  many 
instances  they  have  inflicted  serious  and  irreparable  injury ;  in  one 
instance  which  came  under  my  notice,  the  injury  thus  inflicted  caused 
tetanus  and  death. 

It  is  scarcely  necessary  to  say  that  the  earlier  the  examination  is 
entered  upon,  the  more  readily  will  the  diagnosis  be  made  out ;  and 
if,  unfortunately,  some  time  has  already  elapsed  before  the  patient  is 


38  REPAIR  OF  BROKEN  BONES. 

seen  by  the  surgeon,  and  much  swelling  has  taken  place,  the  exami- 
nation is  still  not  to  be  omitted,  and  whatever  doubts  remain  we  must 
endeavor  to  remove  by  repeated  examinations  made,  from  day  to  day, 
until  the  subsidence  of  the  tumefaction  has  brought  the  surfaces  of  the 
bone  again  within  the  reach  of  our  observation. 


CHAPTER   IV. 

EEPAIK  OF  BROKEN  BONES. 

It  is  not  my  intention  to  enter  very  fully  into  a  consideration  of  the 
process  of  repair  in  fractures,  preferring  to  leave  this  subject  where  it 
more  properly  belongs,  to  the  general  treatises  on  surgical  pathology. 

I  only  propose  to  state  very  briefly  a  few  practical,  and  I  trust  I 
may  now  say,  pretty  well  established  facts,  such  as  the  manner  or 
position  in  which  this  reparative  material,  whenever  it  is  employed, 
is  applied  to  the  broken  bones,  the  length  of  time  which  is  usually 
required  for  the  completion  of  the  process  of  repair,  and  the  causes 
which  may  impede  or  prevent  bony  union. 

If  I  think  it  necessary  to  say  anything  more  upon  this  subject,  it 
will  be  simply  to  announce  my  belief  that  the  reparative  material, 
consisting  originally  of  a  plastic  lymph,  is  poured  out  from  the  vessels 
of  the  Haversian  canals,  the  medullary  tissue,  the  periosteum,  the 
broken  ends  of  the  bone,  and  more  or  less  from  all  of  the  lacerated 
tissues  which  are  immediately  adjacent  to  the  seat  of  fracture ;  that 
after  a  period,  longer  or  shorter,  this  lymph  becomes  organized,  and 
begins  to  receive  from  the  same  sources  particles  of  bony  matter, 
through  which  the  consolidation  is  finally  effected  ;  that  the  transition 
from  the  original  plastic  material  to  bone  is  in  adults  almost  con- 
stantly through  the  interposition  of  connective  tissue,  rarely,  unless  in 
the  case  of  children,  through  a  cartilaginous  tissue,  and  sometimes 
through  both  consentaneously  or  consecatively ;  that,  perhaps,  in  a 
few  fortunate  examples  bones  unite  directly  or  immediately,  without 
the  intervention  of  a  reparative  material ;  and  finally,  that  granula- 
tion tissue  sometimes  becomes  transformed  into  bone,  in  certain  cases 
of  compound  fractures,  or  of  fractures  in  which  the  process  of  inflam- 
mation exceeds  certain  limits. 

'  Dupuytren,  enlarging  upon  the  doctrines  taught  by  Galen,  Duhamel, 
Camper,  and  Haller,  declared  that  "nature  never  accomplishes  the 
immediate  union  of  a  fracture  save  by  the  formation  of  two  successive 
deposits  of  callus ;"  one  of  which  is  derived  from  the  periosteum  and 
from  the  adjacent  tissues,  and  from  the  medulla ;  while  the  other,  de- 
rived, perhaps,  from  the  broken  extremities  of  the  bone  itself,  is  found 
at  a  later  period  directly  interposed  between  these  surfaces.  The 
material  or  callus  derived  from  the  tissues  outside  of  the  bone,  and 
which  Galen  compared  to  a  ferule,  but  which  Mr.  Paget  calls  "  en- 


EEPAIR  OF  BROKEN  BONES.  39 

sheathing,"  together  with  the  material  derived  from  the  medulla,  com- 
pared often  to  a  plug,  and  by  Mr.  Paget  named  "  interior"  callus,  are 
by  Dupuytren  spoken  of  as  the  "  provisional,"  or  temporary  callus, 
by  which  the  fragments  are  supported,  and  maintained  in  contact 
until  the  permanent  callus  is  formed.  This  temporary  splint  is  com- 
pleted, or  has  arrived  at  the  condition  of  bone  in  a  spongy  form,  at 
periods  varying  from  twenty  to  sixty  days ;  but  it  does  not  assume 
the  character  of  compact  bone  until  a  period  varying  from  fifty  days 
to  six  months  has  elapsed ;  after  which  it  is  gradually  removed  by 
absorption.  The  second  process,  by  which  the  ends  of  the  bone  are 
definitively  or  permanently  united,  commences  when  the  provisional 
callus  has  arrived  at  the  stage  of  spongy  bones,  and  is  not  completed 
usually  within  less  than  eight,  ten,  or  twelve  months,  "  when,"  says 
Dupuytren,  "it  acquires  a  solidity  greater  than  the  original  bone." 

While  it  is  certain  that  this  eminent  surgeon  and  most  accurate 
observer  has  described  faithfully  the  various  phenomena  which  usually 
accompany  the  repair  of  bones  in  those  animals  which  were  the 
subjects  of  his  experiments,  and  that  his  conclusions  have  a  certain 
degree  of  application  to  the  human  species,  it  is  equally  certain  that 
he  erred  in  assuming  that  in  man  simple  fractures  always  unite  by 
this  double  process  ;  yet,  such  is  the  power  of  authority,  these  doctrines 
were  accepted  from  the  first  without  hesitation  or  debate,  and  for 
nearly  half  a  century  they  have  occupied  the  minds  of  surgeons,  to 
the  almost  complete  exclusion  of  every  other  theory.  Mr.  Stanley 
was  among  the  first  to  question  the  solidity  of  the  doctrines  of  Dupuy- 
tren, but  it  remained  for  Mr.  Paget  to  fully  expose  their  many  falla- 
cies ;  nor  has  Malgaigne,  although  not  strictly  a  disciple  of  Paget, 
failed  to  detect  certain  of  these  errors. 

I  should  also  do  injustice  to  myself  were  I  not  to  mention  that  at 
the  very  moment  when  Mr.  Paget  was  making  his  observations  upon 
the  specimens  in  "  the  large  collection  of  fractures  in  the  museum  of 
the  University  College,"  I  was  myself  employed  in  similar  researches 
both  among  cabinet  specimens  and  in  the  hospitals  of  this  country  and 
of  Europe ;  and  that  the  conclusions  to  which  -I  had  arrived  were 
nearly  identical  with,  although  the  inferences  were  far  from  being  so 
complete  in  their  detail  as  those  to  which  this  distinguished  patholo- 
gist was  himself  brought.^  I  do  not,  however,  wish  to  make  Mr.  Paget 
responsible  for  any  of  the  opinions  upon  this  subject  which  I  shall 
hereafter  express,  except  so  far  as  they  may  be  found  to  agree  with 
his  own  published  views.^ 

I  think  it  may  now  be  fairly  stated  that  the  repair  of  bones  by  the 
double  process  described  by  Dupuytren  is,  in  man,  only  an  exception 
to  a  very  general  rule ;  and  that  fractures  may  unite  by  either  one  of 
the  following  modes : — 

First.  Immediately,  or  in  the  same  manner  that  the  soft  tissues 
sometimes  unite,  by  the  direct  reunion  of  the  broken  surfaces,  and 
without  the  interposition  of  any  reparative  material.     This  happens 

'  Paper  on  "Provisional  Callus,"  by  Frank  H.  Hamilton.  Buffalo  Medical  Jour- 
nal, Feb.  1853. 
2  Lectures  on  Surgical  Pathology,  by  James  Paget,  Phil,  ed.,  1854,  Chapter  XI. 


AO  EEPAIR  OF  BROKEN  BONES. 

probably  sometimes  in  the  spongy  bones,  and  in  the  extremities  or 
spongy  "portions  of  the  long  bones,  especially  when  one  portion  of  bone 
is  driven  into  another  and  becomes  impacted ;  as  in  certain  fractures 
of  the  neck  of  the  humerus  or  of  the  femur. 

Second,  By  interposition  of  a  reparative  material  between  the  broken 
ends;  as  when  the  fragments  remain  in  exact  apposition,  but  imme- 
diate union  fails.  This  is  especially  apt  to  occur  in  superficial  bones, 
such  as  the  tibia ;  or  upon  those  sides  of  the  bone  which  are  most 
superficial.  It  is  not  an  unusual  circumstance  to  find  the  shaft  of  the 
tibia  during  the  process  of  union  presenting  no  exterior  callus  upon 
its  anterior  and  inner  surface,  whilst  the  posterior  and  outer  section  of 
its  circumference  is  covered  with  an  abundant  deposit.  In  other  cases, 
however,  of  fractures  of  the  shaft  as  well  as  of  the  epiphyses,  the 
intermediate  callus  secures  a  prompt  union,  but  no  ensheathing  callus 
is  ever  formed. 

Third.  Bones  broken  and  not  separated,  unite  occasionally  by  the 
process  described  by  Dupuytren,  namely,  by  the  formation,  first,  of  an 
ensheathing  callus,  whilst  at  the  same  moment  the  cylindrical  cavity 
becomes  closed  by  a  spongy  plug  or  a  compact  septum  of  bone  ;  and 
second,  by  definitive  callus  deposited  between  the  broken  ends.  It  is 
probable  that  this  happens  generally  in  children,  and  it  is  a  common 
mode  of  union  in  the  ribs,  which  bones,  during  the  whole  progress  of 
the  union,  are  necessarily  kept  in  motion.  My  cabinet  furnishes  many 
illustrations  of  ensheathing  callus  in  ribs ;  and  also  a  few  in  fractures 
of  the  tibia  and  fibula. 

Fourth.  Under  similar  circumstances,  where  no  displacement  exists, 
the  fracture  may  unite  by  ensheathing  and  interior  callus  alone,  no  in- 
termediate callus  ever  being  formed  between  the  broken  ends;  in  which 
case  it  may  be  properly  said  that  the  bone  itself  has  never  united,  and 
the  ensheathing  callus,  instead  of  being  provisional,  is  permanent  or 
definitive.  This  was  essentially  the  doctrine  of  Galen,  Haller,  and 
Duhamel  before  Dupuytren  added  his  "  fifth  period,"  or  the  formation 
of  definitive  callus ;  and  by  these  older  surgeons  it  was  held  to  be  of 
universal  application,  except  perhaps  in  the  case  of  children.  To  this 
doctrine  also  Malgaigne  has  returned — at  least  to  the  question  "  Is 
there  always  a  definitive  callus,  or  complete  union  of  the  fragments  ?" 
he  has  made  this  laconic  reply  :  "  Galen  admitted  its  occurrence,  but 
only  in  young  subjects ;  it  has  been  obtained  in  animals,  where  there 
had  been  no  displacement.  I  would  willingly  believe  that  such  is 
sometimes  the  case  in  human  adults ;  but  I  must  confess  I  have  seen 
only  the  instance  above  cited,  which  might  just  as  well  be  used  to 
prove  the  compact  ossification  of  the  provisional  callus."  He  accepts, 
therefore,  the  doctrine  of  Galen  as  having  not  merely  an  occasional 
application,  but  as  explaining  the  process  of  union  in  the  large  ma- 
jority of  cases  ;  and  in  support  of  this  extreme  view  he  finds  that  the 
exterior  callus,  which  Dupuytren  called  provisional  or  temporary,  is 
actually  permanent,  unless  removed  by  the  absorption  consequent 
upon  pressure. 

To  all  of  which  we  can  only  say  that  an  examination  of  five  or  six 
specimens  in  our  own  cabinet,  after  having  carefully  divided  them 


EEPAIE  OF  BROKEN  BONES. 


41 


with  a  saw,  has  furnished  only  one  illustration  of  union  by  ensheathing 
and  interior  callus  alone.  In  each  of  the  other  specimens  the  union 
was  completed  by  definitive  or  intermediate  callus.  We  cannot, 
therefore,  avoid  the  conclusion  that  Malgaigne  has  been  deceived  as 
to  the  relative  frequency  of  these  different  modes  of  union,  and  that 
union  without  intermediate  callus  is  exceptional. 

Fifth.  When  bones  are  broken  and  overlap,  they  may  unite  by  the 
interposition  of  a  callus  between  the  opposing  surfaces,  that  is,  by  an 
intermediate  callus,  but  which  will  differ  from  that  described  as  the 
second  method,  inasmuch  as  the  new  material  will  be  deposited  upon 
the  sides  of  the  fragments  and  not  upon  their  extremities.  The  limb 
being  kept  perfectly  at  rest,  and  all  other  circumstances  proving 
favorable,  this  union  may  take  place  without  any  excess  or  irregularity 
in  the  deposit.  The  surfaces  will  unite  firmly  where  they  are  in  actual 
contact,  and  smooth  and  well-formed  buttresses  will  fill  up  all  the 
spaces  between  the  bones  where  they  are  not  in  actual  contact,  sufS.- 
cient  generally  to  give  the  requisite  strength  to  this  new  bond  of 


Fiff.  3. 


Fisr.  4. 


Fracture  of  the  thigh  of  a  turkey  ;  united  with  the  frag- 
ments widely  separated.  From  a  specimen  in  the  anther's 
cabinet. 

union.  This  mode  of  union  will  be 
completed  sometimes  when  the  two 
ends  of  the  bones  are  separated  later- 
ally an  inch  or  more  from  each  other. 
I  have  in  my  collection  the  bone  of  a 
turkey's  thigh  (Fig.  3)  thus  united  by 
a  transverse  bony  shaft,  although  sepa- 
rated more  than  one  inch  ;  and  what  is 
less  common,  I  possess  also  a  specimen 
of  the  adult  human  thigh  (Fig.  4),  in 
which  an  oblique  shaft  of  solid  callus 
has,  after  many  months,  and  while  no 
splints  were  employed,  bound  together 
firmly  the  two  opposite  extremities  of 
the  broken  bone. 

Sixth.  The  fragments  being  overlap- 
ped more  or  less,  and  suffering  unusual 
disturbance,  or  the  adjacent  tissues 
having  been  much  torn,  or  much  blood 
being  effused,  so  that  considerable  in- 
flammation is  caused,  the  amount  of  cal- 
lus will  exceed  what  is  necessary  for 
4 


Fractureof  the  shaft  of  the  femur  ;  united 
with  an  oblique  callus.  From  a  specimen 
in  the  author's  cabinet. 


42  REPAIR  OF  BROKEN  BOXES. 

the  complete  union  of  the  bones ;  and  this  redundancy  may  be  de- 
posited around  and  upon  the  broken  ends  of  the  bones,  or  anywhere 
in  their  immediate  vicinity,  in  layers,  or  in  masses  of  irregular  shape 
and  size.  Even  the  bones  which  are  not  broken,  but  which  are  near, 
as  in  the  case  of  the  fibula  after  a  fracture  of  the  tibia,  may  become 
inflamed,  or  their  coverings  may  inflame,  and  they  may  also  con- 
tribute to  the  general  mass  of  bony  callus. 

Compound  fractures,  or  rather,  we  ought  to  say,  fractures  accom- 
panied with  granulations  and  suppuration,  obey  no_  uniform  law  of 
repair  so  far  as  the  manner  and  position  of  the  deposit  are  concerned  ; 
but  they  come  together  finally  with  more  or  less  irregular  distributions 
of  ossified  matter,  according  to  the  varying  circumstances  of  imperfect 
coaptation,  mobility,  &c.,  in  which  they  may  chance  to  be  placed. 
Occasionally  the  amount  of  callus  is  less  than  occurs  in  simple  frac- 
tures, and  at  other  times  the  excess  is  very  great. 

That  was,  no  doubt,  a  beautiful  thought,  which  ascribed  the  forma- 
tion of  provisional  callus  to  an  intelligent  efficient  cause,  which  in 
this  manner  sought  to  support  the  fragments  until  a  reunion  of  their 
divided  ends  was  accomplished.     But  the  beauty  of  a  conception 
supplies  no  evidence  of  its  truth;  and  we  have  grave  doubts  whether 
Nature  ever  allows  any  interference  with  her  laws  even  in  an  exigency, 
unless  by  the  substitution  of  a  miracle.     Provisional  callus  is,  in  our 
opinion,  just  as  much  the  necessary  result  of  natural  laws,  as  is  defini- 
tive.    It  is  formed  because  in  that  condition  of  the  parts  and  of  the 
general  life  its  formation  was  inevitable.     Whether  useful  for  the 
purposes  of  repair  or  not,  it  will,  under  certain  circumstances,  exist. 
In  the  repair  of  certain  fractures,  provisional  callus,  it  is  conceded, 
seldom  occurs.     Thus  it  is  with  the  cranium,  the  acromion,  coracoid 
and  olecranon  processes,  the  patella,  and  with  all  those  portions  of 
bones  which  are  immediately  invested  with  a  synovial  capsule.    Will 
it  be  affirmed  that  in  the  examples  just  named  this  callus  is  not  formed 
because  it  is  not  required  ?     To  us  it  seems  that  nowhere  could  it 
prove  more  useful,  since,  with  the  single  exception  of  the  cranium,  it 
is  in  these  very  cases  that  the  obstacles  to  a  reunion  are  the  most 
serious.     In  fractures  of  the  patella,  olecranon,  &c.,  the  action  of  the 
muscles  tends  constantly  and  powerfullv  to  displace  the  fragments,  and 
gladly  would  the  surgeon  avail  himself  of  the  assistance  of  a  tem- 
porary callus,  but  it  is  rarely  present,  at  least  in  any  useful  degree.    So 
also  in  fractures  of  the  neck  of  the  femur  within  the  capsule,  and  in 
other  similar  cases,  we  cannot  say  that  temporary  callus  would  not  be 
advantageous  in  facilitating  the  retention  of  the  fragments,  yet  the 
"intelligent  efficient  agent"  neglects  to  furnish  it. 

The  only  satisfactory  reason  which,  as  we  think,  can  be  assigned  for 
the  absence  of  callus  in  these  cases,  is  found  in  the  doctrines  we  now 
advocate ;  that  is  to  say,  it  is  usually  absent  because  that  amount  of 
excitement  and  irritation  is  usually  absent  which  alone  determines  its 
formation.  In  the  case  of  the  olecranon,  patella,  &c.,  the  fragments 
being  separated  from  each  other  by  muscular  action,  so  that  no  painful 
pinchings  or  chafings  occur,  and  their  rough  surfaces  or  sharp  points 
being  rather  drawn  away  from,  than  protruded  into  the  flesh,  no 


REPAIR  OF  BROKEN  BONES.  48 

sufficient  provocation  exists  for  the  production  of  inflammation  and 
effusion.  Hence  the  failure  of  provisional  callus;  but  wherever  the 
fracture  occurs,  and  however  moderate  the  action,  definite  callus  does 
not  fail ;  still  the  broken  surfaces  of  the  patella  and  olecranon  are 
softened,  and  smoothed,  and  covered  over  with  a  new  matter,  which, 
if  contact  could  have  been  secured  and  preserved,  would  certainly 
have  served  to  consolidate  and  repair  the  breach.  The  natural  re- 
parative process  proceeds,  but  only  the  accidental  process  is  omitted. 
This  latter,  however,  is  seen  again  even  here,  when  from  other  and 
unusual  causes  a  sur-excitement  is  established. 

Temporary  callus  is  not  formed  upon  bones  invested  with  synovial 
membranes,  because  here,  too,  as  in  the  neck  of  the  femur,  there  are 
not  so  many  structures  lacerated  and  irritated,  and  the  supply  of  this 
effusion  must  be  the  less  not  only  in  proportion  to  the  less  intensity 
of  the  inflammation,  but  also  to  the  less  amount  of  structures  impli- 
cated. 

Possibly  other  -and  more  satisfactory  reasons  may  be  assigned  why 
provisional  callus  is  not  formed  usually  when  the  neck  of  the  femur 
is  broken  within  the  capsule ;  but  we  certainly  can  never  admit  the 
common,  and,  as  here  applied,  the  too  palpably  absurd  explanation, 
that  it  is  not  wanted.  It  is  wanted,  and  in  no  case  so  much  as  in  the 
one  now  supposed. 

Provisional  callus  has,  therefore,  no  final  purpose,  but  it  is  the 
unavoidable  result  of  certain  abnormal  conditions.  It  still  occurs 
everywhere  when  against  and  in  the  vicinity  of  the  bone  there  is  the 
requisite  lesion  and  action,  and  it  will  occur  as  certainly  when  there 
is  no  fracture  at  all,  but  only  a  caries,  a  necrosis,  or  a  simple  bony  or 
periosteal  inflammation;  and  whilst  it  is  doubtless  true  that  in  frac- 
tures it  sometimes  renders  valuable  aid  to  the  surgeon,  it  is  equally 
true  that  it  often  proves  a  source  of  hindrance. 

From  these  remarks  I  choose  to  except  fractures  occurring  in  chil- 
dren, in  relation  to  which  the  observations  are  not  yet  sufficiently 
numerous  to  determine  absolutely  the  laws  of  repair.  If,  however,  I 
were  to  venture  an  opinion  based  upon  a  few  examinations,  I  should 
say  that  in  children  we  may  accept  with  but  little  qualification  the 
doctrine  of  Dupuytren  as  already  explained. 

Dupuytren,  in  determining  the  limits  of  his  "third"  period,  or  of 
that  in  which,  a  provisional  callus  is  formed  of  sufficient  strength  to 
support  the  fragments,  has  given  what  has  been  usually  quoted  as  the 
natural  period  within  which  bones  may  be  said  to  be  united,  that  is, 
"from  the  twentieth  or  twenty-fifth  day,  to  the  thirtieth,  fortieth,  or 
sixtieth."  But  this  depends  so  much  upon  the  age  of  the  patient,  his 
general  condition  of  health,  the  condition  and  position  of  the  broken 
ends,  as  well  as  upon  the  bone  itself,  and  the  point  at  which  it  is 
broken,  with  many  other  circumstances,  that  it  would  be  unsafe  to 
establish  any  absolute  laws  in  reference  to  this  point. 

In  very  early  infancy,  union  is  accomplished  in  half  the  time  re- 
quired in  adult  life,  and  it  is  generally  thought  to  be  still  more  re- 
tarded in  advanced  ag-e,  but  Malg-aigne  has  not  found  this  latter 
observation  confirmed  by  his  own  experience.     V  arious  constitutional 


44         GENERAL  TREATMENT  OF  FRACTURES. 

causes,  as  we  shall  hereafter  explain  more  fully,  retard  bony  union. 
Motion,  also,  sometimes  delays  consolidation :  fragments  which  are 
overlapped  do  not  unite  as  speedily  as  those  which  are  placed  end  to 
end,  and  other  complications  interfere  in  a  similar  manner,  such  as 
lesions  of  nerves,  of  bloodvessels,  comminution  of  the  bone,  the  inter- 
position between  the  ends  of  the  fragments  of  a  blood-clot,  a  portion 
of  muscular,  tendinous,  or  other  tissue,  &c.  In  general  the  bones  of 
the  lower  extremities,  independently  of  their  size,  unite  more  slowly 
than  the  bones  of  the  upper  extremities. 

Epiphyses,  when  separated,  unite  by  the  same  process  as  fractures 
of  the  bone.  It  is  affirmed,  however,  that,  when  certain  epiphyses 
unite  with  much  displacement,  the  shafts  from  which  they  have  been 
separated  cease  to  grow,  and  the  limbs  become  atrophied. 

For  a  more  complete  consideration  of  the  causes  which  retard  the 
union  of  bones,  I  beg  to  refer  the  reader  to  the  chapter  on  "  Delayed 
Union,  and  Non-Union  of  Bones.'' 


CHAPTER   V. 

GENERAL  TREATMENT  OF  FRACTURES. 

All  that  has  been  said  in  relation  to  the  propriety  of  handling  a 
broken  limb  gently  when  the  surgeon  is  examining  the  position  and 
character  of  the  fracture,  is  equally  applicable  to  the  lifting  and  trans- 
porting of  the  patient  to  his  bed,  to  the  removal  of  the  clothing,  and 
to  the  general  management  of  the  limb  before  it  is  dressed.  Rude  or 
awkward  manipulations,  by  which  needless  pain  is  inflicted,  are  not 
simply  acts  of  wanton  cruelty,  but  they  are  sources,  and  I  think  I 
may  say  frequent  sources,  of  inflammation,  suppuration,  and  gangrene. 
Here,  as  in  all  the  subsequent  handlings,  everything  should  be  done 
slowly,  thoughtfully,  and  systematically.  Yet  it  is  difficult  to  state 
the  precise  manner  in  which  the  surgeon  ought  to  proceed.  Much 
will  depend  upon  the  circumstances  of  the  case,  something  upon  one's 
natural  tact,  and  upon  the  amount  of  experience,  but  more,  I  think, 
upon  natural  kindness  of  heart,  and  social  education.  The  man  of 
refinement  and  sensibility  will  know  instinctively  how  to  proceed, 
and  needs  no  instruction.  They  who  lack  these  qualities  can  never 
learn,  and  it  would  be  quite  useless  to  undertake  to  teach  them.  I 
sincerely  wish  such  men  as  these  latter  would  find  some  more  suitable 
employment  than  the  practice  of  a  humane  art. 

Nearly  all  fractures  present  three  principal  indications  of  treatment, 
namely:  to  restore  the  fragments  to  place  as  completely  as  possible; 
to  maintain  them  in  place ;  and  to  prevent  or  to  control  inflammation, 
spasms,  and  other  accidents. 

It  ought  to  be  regarded  as  a  rule,  liable  only  to  rare  exceptions, 
that  broken  bones  should  be  restored  to  place,  or  to  the  position  in 


GENERAL  TREATMENT  OF  FRACTURES.         45 

which  we  hope  to  maintain  them,  as  soon  as  possible  after  the  occur- 
rence of  the  accident.  If  the  patient  is  seen  within  the  first  few  hours, 
or  before  much  swelling  has  taken  place,  we  scarcely  know  the  cir- 
cumstance which  would  warrant  an  omission  to  adjust  the  fragments 
either  end  to  end  or  side  by  side,  as  the  one  or  the  other  might  be 
found  to  be  practicable.  We  have  before  sufficiently  explained  the 
general  impossibility  of  again  restoring  to  place,  end  to  end,  and  fibre 
to  fibre,  fragments  which  have  been  made  to  override.  We  are  there- 
fore in  no  danger  of  being  understood  to  say  that  bones  should  in  all 
cases  be  immediately  "set,"  in  the  popular  sense  of  this  term.  They 
ought  to  be  "  set,"  no  doubt,  if  this  can  be  accomplished  through  the 
application  of  a  prudent  amount  of  force;  but  if  they  cannot  be  thus 
placed  end  to  end,  they  may  at  least  be  laid  in  such  a  manner  side  by 
side  as  to  restore,  in  some  measure,  the  natural  axis  of  the  limb,  and 
prevent  the  points  of  the  bone  from  pressing  unnecessarily  into  the 
flesh. 

Experience  has,  indeed,  furnished  us  with  four  or  five  very  good 
reasons  why  broken  bones  should  be  reduced  as  soon  as  possible. 
When  the  injury  is  recent,  the  muscles  offer  less  resistance;  their 
resistance  being  increased  after  a  time  not  only  by  the  reaction  which 
ensues  upon  the  shock,  but  also  by  actual  adhesion  between  their 
fibres;  effusions  distend  both  the  muscles  and  the  skin,  and  compel 
the  limb  to  shorten;  the  constant  goading  of  the  flesh  by  the  sharp 
points  of  the  broken  bones  increases  the  muscular  contractions ;  the 
patient  will  submit  readily  to  manipulation  and  extension  at  first,  but 
after  the  lapse  of  a  few  days  it  is  very  seldom  that  he  will  permit  the 
limb  to  be  in  any  manner  disturbed,  even  if  he  is  assured  that  his 
refusal  entails  upon  him  a  great  deformity.  If  it  is  true  that  no  callus 
or  bony  structure  is  deposited  earlier  than  the  seventh  or  tenth  day, 
it  is  also  true  that  the  renewed  attempt  to  adjust  the  bones  at  this 
period,  by  chafing  and  tearing  again  the  tissues,  reduces  the  fracture, 
in  some  degree,  to  the  same  condition  in  which  it  was  at  first,  and, 
consequently,  the  time  which  has  elapsed,  or,  at  least,  a  portion  of  it, 
may  be  regarded  as  lost. 

We  cannot,  therefore,  understand  the  argument  by  which  Brom- 
field,  South,  and  a  few  other  surgeons  have  persuaded  themselves 
that  reduction  should  never  be  attempted  before  the  third  or  fourth 
day;  nor,  indeed,  do  we  fully  appreciate  the  refinement  which  Mal- 
gaigne  has  given  to  this  question  in  itself  so  simple.  To  affirm  that 
we  ought  not  to  reduce  the  bones  to  their  original  positions  during 
the  period  of  intense  inflammation,  or  of  great  swelling,  or  while  the 
muscles  are  acting  spasmodically,  is  only  to  affirm  that  we  may  noL 
do  what  is  impossible ;  and  the  attempt  to  do  which,  therefore,  can 
only  be  mischievous ;  but  to  authorize  their  restoration  to  a  better 
position,  by  such  manipulation,  extension,  and  lateral  support  as  they 
may  comfortably  bear,  is  warrantable  under  any  circumstances.  The 
practice  is  not  only  defensible,  but  imperative,  and  we  do  not  think 
any  really  sound  and  practical  surgeon  ever  intended  to  teach  the 
contrary.  We  say  still,  if  bones  can  be  easily  reduced,  or  the  position 
of  the  fragments  improved  at  any  moment  or  under  any  circumstances, 


46 


GEXEEAL  TREATMENT  OF  FRACTURES. 


Fi.ar.  5. 


Fis.  6. 


Application  of  the  "roller"  hy  circular  and  re- 
versed turns. 


Maay-tailed  bandage. 

it  ought  to  be  done ;  and  if  we  fail 
in  accomplishing  all  that  we  wish 
to  do  in  the  first  instance,  we 
must  remain  incessantly  watchful 
to  seize  the  earliest  opportunity 
which  presents,  to  complete  the 
adjustment.  No  doubt  our  efforts 
will  prove  fruitless  very  much  in 
proportion  to  the  amount  of  swell- 
ing, inflam.mation,  or  muscular 
spasm  which  exists,  and  also  in 
proportion  to  the  time  which  has 
elapsed,  but  this  will  not  excuse 
us  for  omitting  to  do  all  which  the 
circumstances  permit. 
It  has  been  the  practice  of  most  surgeons,  for  a  long  period,  to  cover 
the  broken  limb  with  some  form  of  a  bandage  or  roller  before  apply- 
ing the  lateral  splints. 

Of  these  primary  dressings  there  are  two  principal  varieties :  first, 
the  "roller"  or  simple  bandage,  applied  to  the  limb  in  circular  and 
reversed  turns ;  and,  second,  the  "  many-tailed  bandage,"  consisting  of 
a  piece  of  muslin,  or  other  cloth,  torn  down  from  each  side  into  a 
suitable  number  of  strips,  leaving  the  centre,  which  is  to  be  applied 
to  the  back  of  the  limb,  entire. 

A  modification  of  this  latter  bandage  consists  of  a  number  of  separate 
strips,  so  laid  upon  one  another,  commencing  from  above,  as  that  each 
strip  shall  overlap  the  other  by  one-third  or  one-half  of  its  breadth. 
This  is  called  the  bandage  of  Scultetus,  and  it  possesses  one  advantage 
over  the  many-tailed  bandage  just  described,  especially  in  the  case  of 
compound  fractures,  in  the  facility  with  which  each  separate  piece 
may  be  removed  and  another  substituted.  Some  surgeons  prefer  to 
form  the  bandage  of  separate  strips,  and  having  overlaid  them  in  the 
manner  directed,  to  unite  them  again  into  one  by  running  a  thread 
through  the  whole  mass  along  the  centre. 

Whichever  of  these  several  varieties  of  strips  are  employed,  the 
mode  of  applying  them  is  the  same.     They  are  folded  alternately 


GENERAL  TREATMENT  OF  FRACTURES. 


4T 


around  the  limb,  being  made  to  overlap  and  cross  upon  each  other  in 
front,  and  only  the  last  strip  or  two  is  fastened  with  a  pin. 


Fig.  7. 


Fig.  8. 


I 


Application  of  the  many-tailed  bandage. 


Bandage  of  Scultetus. 


The  object  proposed  in  the  use  of  the  roller  or  of  the  many-tailed 
bandage  is  twofold :  first,  to  compress  and  support  the  muscles,  by 
which  their  tendency  to  contraction  is  in  some  measure  controlled ; 
and  second,  to  protect  the  limb  against  the  direct  pressure  of  the  side 
splints. 

A  moment's  consideration  will  convince  us  that  the  first  of  these 
objects  is  in  most  cases  fully  attained  by  the  lateral  splints  themselves, 
and  by  the  bandages  by  which  they  are  retained  in  place ;  and  that 
the  second  can  be  as  well  accomplished  by  a  single  fold  of  cloth,  or  by 
the  compresses,  which  ought  generally,  even  when  the  roller  is  used, 
to  underlie  the  splints.  Nevertheless,  we  should  hardly  feel  authorized 
to  reject  these  primary  dressings  solely  because  the  splints  and  com- 
presses furnish  a  convenient  substitute,  especially  since  we  are  com- 
pelled to  admit  that  they  are  occasionally  useful,  unless  objections  of  a 
more  serious  nature  could  be  brought  against  them.  Unfortunately 
this  latter  supposition  is  actually  true.  By  ligating  the  limb  com- 
pletely, leaving  no  point  of  the  tegumentary  surface  to  which  the 
pressure  is  not  applied,  they  too  often  occasion  congestion,  inflamma- 
tion, and  gangrene.  It  is  not  until  lately  that  the  attention  of  surgeons 
has  been  sufficiently  called  to  this  subject ;  but  the  records  of  surgery 
are  to-day  filled  with  these  terrible  accidents,  formerly  attributed  to 


48         GENERAL  TREATMENT  OF  FRACTURES. 

the  original  injury  or  to  the  splints  themselves,  but  now  understood 
to  be  plainly  traceable  to  the  too  common  employment  of  the  primary 
bandage.  The  roller  is  by  far  the  most  dangerous  dressing  of  the  two, 
since  it  does  not  yield  to  the  swelling  so  readily  as  the  bandage  of 
strips,  and  it  is  more  objectionable  also  on  account  of  the  inconve- 
nience of  applying  and  removing  it;  but  even  the  bandage  of  strips 
may  be  so  confined  as  to  produce  the  same  consequences,  as  I  have 
myself  seen  in  more  than  one  instance.  It  is  also  all  the  more  dan- 
gerous in  the  hands  of  the  inexperienced  surgeon,  because  he  feels 
a  confidence  that  it  will  not  cause  ligation. 

Except  in  rare  cases  and  for  especial  reasons,  which  we  shall  attempt 
to  indicate  in  their  appropriate  places,  we  cannot  recommend  the  em- 
ployment of  any  kind  of  bandages  next  to  the  skin. 

In  order  to  fulfil  the  second  indication,  namely,  to  maintain  the 
frao^ments  in  place,  we  employ  usually  what  are  called  short,  side,  or 
coaptation  splints,  and  long  or  extending  splints,  or  the  weight  and 
pulley. 

Side-splints  may  be  constructed  from  various  materials,  according 
to  the  size  and  circumstances  of  the  limb,  or  according  to  the  conve- 
nience of  the  surgeon  ;  and  as  the  surgeon  cannot  be  expected  to  have 
always  on  hand,  at  the  bedside  of  the  patient,  such  splints  as  he  might 
prefer  to  use,  it  is  well  for  him  to  understand  how  to  avail  himself  of 
such  materials  as  may  be  within  his  reach,  in  order  that  he  may  make 
the  most  of  his  sometimes  imperfect  resources. 

Lead,  sheet-iron,  zinc,  and  other  metals  have  been  occasionally  em- 
ployed, but  especially  tin  and  copper,  which  possess  all  of  the  requisite 
firmness  and  malleability  to  allow  them  to  be  hammered,  and  thus 
moulded  to  the  limb.  In  general,  however,  they  are  unnecessarily 
heavy,  and  demand  too  much  labor  to  be  wrought  into  shape.  I  have 
sometimes  employed  tin  splints  perforated  with  large  fenestrse  to 
diminish  their  weight  and  increase  their  flexibility,  and  found  them 
to  answer  an  excellent  purpose.  The  light  perforated  zinc  splints, 
introduced  into  the  U.  S.  Army  by  the  Sanitary  Commission,  through 
the  agency  of  Dr.  E.  Harris,  of  New  York,  were  found  exceedingly 
useful. 

Iron-wire  splints,  made  from  wire-cloth  or  coarse  gauze,  were  first 
publicly  mentioned,  so  far  as  I  can  learn,  in  a  communication  to  the 
Memphis  Medical  Recorder,  made  by  Dr.  J.  C.  Nott,  of  Mobile ;  but  they 
have  been  brought  more  particularly  into  notice,  and  their  construction 
perfected,  by  Louis  Bauer,  of  New  York.'  These  splints  are  moulded 
upon  "  gypsum  or  wooden  casts,"  of  different  sizes,  and  surrounded  with 
a  stout  iron  wire  frame,  in  order  to  give  them  the  requisite  degree  of 
firmness,  and  to  preserve  their  forms ;  after  which  they  are  tinned  by 
galvanism,  and  varnished,  to  prevent  them  from  becoming  rusted. 
When  applied.  Dr.  Bauer  recommends  that  they  shall  be  filled  with 
loose  cotton,  and  that  they  shall  be  held  in  place  by  rollers.  It  is 
claimed  for  these  splints  that  they  are  light,  flexible,  permeable  to  air 
and  to  the  perspiration,  and  that  they  permit  the  application  of  cool- 

•  Nott  and  Bauer,  Buf.  Med.  Journ.,  vol.  xii.,  April,  1857. 


GENERAL  TREATMENT  OF  FRACTURES.         49 

ino-  lotions  without  impairing  their  firmness ;  the  last  of  which  is  a 
quality  of  questionable  value,  since  lotions  applied  to  permanent 
dressings  of  any  kind  are  only  warm  fomentations,  and  do  not,  there- 
fore, in  this  respect  serve  the  purpose  for  which  they  were  intended ; 
besides  that  they  render  the  skin  tender,  and  disposed  to  vesicate, 
they  give  rise  to  a  sensation  of  scalding,  which  is  sometimes  almost 
intolerable;  they  soak  into  the  bed,  and  in  many  other  ways  render 
the  patients  uncomfortable.  Cooling  lotions  are  only  applicable  where 
the  dressings  are  open,  loose,  and  temporary. 

The  same  objections  hol(3  also  to  this  as  to  all  other  forms  of 
moulded  metallic,  or  carved  wooden  splint,  namely,  that  they  seldom 
exactly  fit  the  limb,  even  when  the  supply  of  assorted  sizes  is  com- 
plete, and  that  they  are  not  sufficiently  flexible  to  adapt  themselves 
to  anything  but  the  slightest  irregularity  of  surface.  They  are  not, 
however,  without  merit,  and  they  deserve  at  least  a  qualified  recom- 
mendation in  many  cases,  I  shall  refer  to  them  again  when  speaking 
of  fractures  of  the  thigh  and  leg. 

Horn  and  whalebone  may  be  employed  in  thin  plates,  or  in  the 
form  of  narrow  strips  quilted  into  cloth ;  but  they  are  expensive,  and 
possess  no  special  value  except  in  an  emergency.  Eeeds,  the  coarse 
rank  grass  which  grows  in  swamps,  flags,  willow  branches,  and 
unbroken  wheat  straw,  may  be  quilted  between  two  thicknesses  of 
cloth  in  the  same  manner,  and  form  very  excellent  temporary  splints. 
I  have  especially  found  it  convenient  to  use  wheat  straw  in  the  form 
of  junks.  Gathering  up  a  bundle  of  unbroken  straws  of  the  size  of 
my  arm,  I  roll  them  snugly  in  a  broad  piece  of  cotton  cloth,  cut  off 
the  projecting  ends,  and  then  stitch  up  the  cloth  neatly.  We  have 
thus  a  splint  of  considerable  firmness,  and  one  which  is  cool  and 
especially  adapted  to  the  summer,  allowing  the  perspiration  to  evapo- 
rate freely.  Straw  splints  were  employed  sometimes  by  Ambriose 
Par^,  by  J.  L.  Petit,  Larrey,  and  I  have  several  times  seen  them  in 
the  wards  of  certain  European  hospitals,  although  I  am  unable  now 
to  say  under  whose  direction.  Mr.  Tuffnell,  of  Dublin,  has  especially 
recommended  them  in  the  form  of  junks.' 

Wooden  splints,  made  of  pine,  willow,  white  or  linden  wood,  or  of 
some  other  light  and  easily  wrought  timber,  are  probably  of  more 
universal  application,  and  possess  greater  intrinsic  value  than  splints 
constructed  from  any  other  material ;  but  I  wish  at  once,  and  for  all, 
to  disclaim  any  intention  of  giving  even  a  qualified  approval  of  any 
of  those  carved,  polished,  and  generally  patented  wooden  splints,  which 
are  manufactured  and  sold  by  clever  mechanics,  and  which  one  may 
see  suspended  in  almost  every  doctor's  office,  whether  in  the  city  or 
in  the  country.  Constructed  with  grooves  and  ridges,  and  variously 
inclined  planes,  for  the  avowed  purpose  of  meeting  a  multitude  of 
indications,  such  as  to  protect  a  condyle,  to  press  between  parallel 
bones,  to  follow  the  subsidence  of  a  muscular  swelling,  &c.,  they  never 
meet  exactly  a  single  one  of  these  indications,  whilst  they  seldom  fail 
to  defeat  some  other  indication  of  equal  importance.     They  deceive 

Tufihell,  New  York  Journ.  Med.,  March,  1847,  p.  364. 


50         GENEKAL  TREATMENT  OF  FRACTURES. 

especially  the  inexperienced  surgeon  into  the  belief  that  he  has  in  the 
splint  itself  a  provision  for  all  these  wants,  and  consequently  lead  him 
to  neglect  those  useful  precautions  which  he  would  otherwise  have 
adopted. 

If  carved  wooden  splints  are  employed,  they  ought  to  be  made 
especially  for  the  case  under  treatment.  But  this  requires  time  and 
some  more  mechanical  skill  than  can  always  be  commanded;  and 
when  accurately  fitted,  it  is  quite  probable  that  the  subsidence  or 
increase  of  the  swelling  will,  within  the  next  forty-eight  hours,  render 
some  change  in  the  form  of  the  splint  necessary,  or  compel  the  sur- 
geon to  throw  it  aside. 

We  much  prefer  to  use  plain,  straight  strips  of  wood,  of  the  re- 
quisite width  and  length,  which  may  be  cut  at  any  moment  from  a 
shingle  or  a  thin  piece  of  board. 

In  order  that  these  splints  may  adapt  themselves  to  the  inequalities 
of  the  limb,  and  properly  support  the  fragments,  they  may  be  under- 
laid with  pads  or  junks  of  a  suitable  thickness ;  or,  what  is  still  better, 
they  may  be  covered  with  a  muslin  sack,  open  at  both  ends,  into 
which,  and  on  the  side  of  the  splint  which  is  to  be  placed  against  the 
limb,  bran,  wool,  cotton  batting,  or  curled  hair  may  be  pressed,  until 
it  is  made  to  fit  accurately.  I  generally  prefer  cotton  batting.  Bran 
is  liable  to  get  displaced,  and  curled  hair  does  not  pack  firmly  enough. 
When  the  sack  is  sufl&ciently  filled,  the  two  ends  must  be  stitched  up. 
This  mode  of  constructing  the  splint  is  simple  and  easy  of  accomplish- 
ment ;  the  sphnt  can  be  fitted  very  accurately  ;  the  pad  never  becomes 
displaced;  and  when  the  bandages  are  applied,  they  may  be  pinned 
or  sewed  to  the  cover  in  such  a  way  that  they  shall  not  slide  or  loosen. 

If  pads  are  employed  separate  from  the  splint — and  for  this  purpose, 
also,  I  generally  prefer  the  cotton  batting — they  ought  to  be  made  and 
fitted  with  the  same  care,  and  neatly  stitched  together  at  their  ends, 
rather  than  pinned.  Cotton  batting  laid  loosely  next  to  the  skin,  or 
underneath  the  splints  at  any  point,  will  not  keep  its  place  so  well  as 
when  it  is  inclosed  in  covers — it  is  more  liable  to  get  into  knots,  and 
it  has  altogether  a  slovenly  appearance.  The  pads  may  be  stitched 
to  the  roller,  and  in  this  way  secured  effectually  in  place,  but  loose 
cotton  is  subject  to  no  control. 

When  I  speak  of  pads,  it  must  not  be  understood  that  I  intend  to 
recommend  them  for  compresses,  or  for  the  purpose  of  pressing  frag- 
ments into  place.  Nothing  could  be  a  greater  source  of  mischief  in 
the  dressing  of  a  broken  limb.  I  have  only  directed  their  employ- 
ment as  a  means  of  adaptation,  and  to  protect  the  skin  against' the 
direct  pressure  of  the  splint. 

Dr.  Jacobs,  of  Dublin,  says  that  he  has  seen  an  excellent  splint 
made  from  the  "  fresh  bark  of  a  tree,  taken  off'  while  the  sap  is  rising." 
"It  fits  admirably,"  says  Dr.  Jacobs,  "just  like  pasteboard  soaked  in 
water."'  Dr.  C.  C.  Jewett,  of  the  20th  Mass.  Vols.,  recommends  for 
the  same  purpose  the  bark  of  the  liriodendron,  or  tulip-tree. 

Undressed  sole-leather,  cut  into  shape  and  soaked  a  few  minutes  in 

• 
'  Jacobs,  New  York  Journ.  Med.,  March,  1847,  p.  265,  from  Dublin  Med.  Press. 


GENERAL  TREATMEXT  OF  FRACTURES. 


51 


Fis:.  9. 


Wood  and  leather  splint. 


water,  adapts  itself  easily  to  the  limb  and  is  sufficiently  firm.  It  is 
especially  applicable  to  fractures  of  the  larger  limbs.  At  Bellevue 
Hospital  it  has  for  several  years  taken  the  place  of  almost  all  other 
materials. 

A  splint  is  also  occasionally  made  of  thin  calfskin  veneered  with 
some  light  timber,  such  as  linden  or  white  wood,  the  latter  being  sub- 
sequently split  into  strips  of  from  half  an  inch  to 
one  inch  in  width,  so  as  to  combine  a  certain  degree 
of  flexibility  with  the  requisite  firmness. 

The  Turks  use,  according  to  Sedillot,  in  a  similar 
manner,  the  "nervures"  of  palm  laid  upon  sheep- 
skin and  fastened  with  wooden  thongs  ;^  and  Dr. 
Packard  mentions  that  he  has  seen  narrow  slips  of 
some  light  wood  glued  in  the  same  way  upon  soft 
pieces  of  buckskin,  and  then  fastened  together  with 
two  strips  of  buckskin,  which  were  also  glued  to 
the  splints.^ 

Common,  unpolished  pasteboard,  cardboard,  or 
the  stout  millboard  used  by  bookbinders,  constitute  invaluable  do- 
mestic resorts,  since  they  can  generally  be  found  in  the  house  of  the 
patient ;  and  if  in  no  other  way,  pasteboard  may  generally  be  had  at 
the  expense  of  some  paper  box  or  of  the  loose  cover  of  some  old  book. 
For  small  bones,  the  thinner  sheets  afford  a  sufficient  support ;  but  for 
large  bones  the  thick  binders'  board  is  necessary.  In  preparing  the 
latter  for  use,  it  ought  to  be  moistened  with  water ;  but  if  soaked  too 
much  it  will  separate  and  fall  into  pieces,  or  lose  its  firmness  when 
dry,  in  consequence  of  having  parted  with  some  of  its  paste.  This 
splint  may  be  applied  to  the  limb  without  the  interposition  of  any- 
thing.but  a  few  folds  of  muslin  cloth,  or  a  piece  of  flannel ;  or  we  may 
use  instead  a  single  sheet  of  cotton  wadding.  It  must  be  bound  to 
the  limb  by  the  roller  while  it  is  moist,  and  as  it  dries  speedily  it 
forms  a  smooth,  firm,  and  reliable  splint. 

Felt,  made  of  wool  saturated  with  gum  shellac,  and  pressed  into 
sheets,  makes  an  excellent  moulding  tablet  for  splints.  This  may  be 
obtained  at  any  hat  manufactory.  Until  recently  they  were  manu- 
factured, and  moulded  into  a  great  variety  of  forms,  by  Dr.  David 
Ahls,  at  York,  Pennsylvania.  A  much  cheaper  material,  however, 
and  which  has  nearly  all  the  qualities  of  the  real  felt,  may  be  made 
from  old  pieces  of  broadcloth,  or  from  any  similar  closely  woven 
texture,  by  saturating  it  thoroughly  with  gum  shellac,  the  gum  being 
dissolved  in  alcohol  in  the  proportions  of  one  pound  of  the  former  to 
two  quarts  of  the  latter.  Thus  prepared,  it  is  to  be  spread  upon  both 
surfaces  of  the  cloth  with  a  common  paint-brush.  When  this  first 
coat  is  well  dried  by  suspending  the  cloth  where  the  air  will  have 
free  access  to  both  surfaces,  a  second  must  be  spread  upon  one  of  the 
surfaces;  and  then  a  third;  the  cloth  being  allowed  to  dry  after  each 
successive  coat.     Finally,  the  sheet  is  to  be  folded  upon  itself,  so  as  to 


'  Amer.  Journ.  Med.  Sci.,  vol.  xxiii.,  Feb.  1839,  p.  481. 
2  Packard's  edition  of  Malgaigne,  vol.  i.  p.  173. 


52         GENEEAL  TREATMENT  OF  FRACTURES. 

brines  the  most  thickly  covered  surfaces  together,  and  pressed  with  a 
hot  flat.  If  it  is  necessary  to  have  greater  strength,  more  gum  may 
be  laid  upon  the  cloth,  and  it  may  be  again  folded  and  pressed.  When 
used,  it  is  to  be  dipped  into  boiling  water  or  held  near  the  fire  until 
it  becomes  flexible.  It  hardens  very  rapidly  in  cooling,  and  demands, 
therefore,  some  quickness  in  its  application ;  but  once  applied  and 
fitted,  it  forms  a  hard  but  smooth  splint,  well  adapted  for  all  the 
purposes  for  which  it  is  designed.  It  is  well  to  mention,  if  one  wishes 
to  keep  any  portion  of  the  solution  which  is  not  used,  that,  in  order  to 
prevent  evaporation,  the  vessel  in  which  it  is  contained  must  be  closely 
covered. 

The  principal  objection  to  all  of  those  forms  of  splints  which  con- 
tain gum  shellac  is,  that  they  harden  so  rapidly  after  being  made 
flexible  by  exposure  to  heat,  that  it  is  often  found  difficult  to  give 
them  an  accurate  mould  to  the  limb. 

Dr.  Jacobs  says  he  has  sometimes  found  an  old  hat  to  furnish  a  very 
efficient  splint  in  the  small  fractures  of  children. 

It  has  been  objected  to  the  felt  splint  occasionally,  that  it  is  imper- 
vious to  air  and  moisture,  and  that  it  confines  the  insensible  perspira- 
tion ;  an  objection  which  may  be  obviated  in  some  measure  by  rubbing 
the  surface  which  is  to  be  laid  against  the  limb,  with  pumice-stone, 
until  it  is  roughened  or  until  a  short  nap  is  raised.  But  as  I  never 
use  splints  of  any  kind  without  underlaying  them  with  compresses 
which  act  sufficiently  as  absorbents,  I  have  never  been  aware  of  any 
inconvenience  from  this  source. 

Within  a  few  years,  sheets  of  gutta  percha  have  been  brought  into 
the  market,  varying  in  thickness  from  one-sixteenth  to  one-quarter  of 
an  inch ;  the  use  of  which  for  side  splints  was  first  suggested  and 
practised  by  Oxley,  of  Singapore.  For  fractures  of  the  thigh,  and  for 
the  large  bones  generally,  I  prefer  a  thickness  of  about  one-sixth  or 
one-fifth  of  an  inch;  but  for  the  fingers  or  toes  it  need  not  be  more 
than  one-sixteenth  of  an  inch  in  thickness.  In  its  natural  state,  and  at 
the  ordinary  temperature  of  the  body,  it  is  nearly  as  hard  and  as  in- 
flexible as  bone;  but  when  immersed  in  hot  water  it  almost  imme- 
diately softens,  and  would  become  too  soft  to  be  conveniently  handled 
unless  soon  removed.  It  can  therefore  be  adapted  to  any  surface, 
however  irregular,  and  its  form  may  be  changed  as  often  as  may  be 
necessary.  It  does  not  harden  as  rapidly  as  felt,  and  it  possesses, 
therefore,  in  this  respect,  an  advantage,  since  it  allows  the  surgeon 
more  time  for  adjustment;  while,  on  the  other  hand,  it  hardens  much 
more  rapidly  than  either  starch,  paste,  or  dextrine.  Ten  or  twenty 
minutes  is  all  the  time  usually  required  for  gutta  percha  to  acquire 
that  degree  of  firmness  which  will  prevent  it  from  yielding  under  the 
pressure  of  a  bandage. 

To  use  gutta  percha  skilfully  requires  some  experience,  and  I  have 
known  surgeons  to  reject  it  after  a  single  trial ;  but  by  those  who 
have  acquired  the  necessary  skill  it  is  generally  regarded  as  an  invalu- 
able resource. 

When  constructing  from  this  material  a  thigh-splint,  we  should 
order  a  very  large  tin  pan,  or  some  open,  flat  tray,  in  which  we  may 


GEXEEAL  TREATMEXT  OF  FRACTUEES.         53 

lay  the  splint  at  full  length.  If  the  splint  is  required  to  be  twelve 
inches  long,  and  six  inches  wide,  we  must  cut  it  about  fourteen  inches 
long  by  seven  wide,  so  as  to  allow  for  the  contraction  which  always 
takes  place  more  or  less  when  the  hot  water  is  applied.  It  is  then  to 
be  laid  upon  a  sheet  of  cotton  cloth  of  more  than  twice  the  width  of 
the  splint,  in  order  that  the  cloth  may  envelop  it  completely  when  it  is 
folded  upon  it;  and  the  cloth  should  be  enough  longer  than  the  splint 
to  enable  us  to  handle  and  lift  it  by  the  two  ends  without  immersing 
our  fingers  in  the  hot  water.  Beside,  if  the  gum  is  not  thus  covered 
and  supported,  it  will  adhere  to  the  vessel,  to  the  fingers,  to  the  surface 
of  the  limb,  and  indeed  to  whatever  else  it  comes  in  contact  with;  it 
may  even  fall  to  pieces,  or  become  very  much  stretched  and  distorted 
by  its  own  weight.  The  cloth  cover  will  generally  adhere  to  the 
splint,  and  may  be  permitted  to  remain  upon  it  permanently. 

Place  the  splint,  thus  covered,  in  the  basin,  and  pour  on  the  water 
slowly.  As  soon  as  it  is  sufficiently  softened,  lay  it  over  the  limb, 
moulding  it  carefully  with  the  hands,  or  by  pressing  it  against  the 
.limb  with  a  pillow.  If  it  does  not  harden  rapidly  enough,  this  process 
may  be  hastened  by  sponging  the  outer  surface  with  cold  water;  and 
as  soon  as  it  has  acquired  sufficient  firmness  to  support  itself,  it  may 
be  removed  and  immersed  in  a  pail  of  cold  water  or  placed  under  a 
hydrant ;  after  this,  it  is  to  be  neatly  trimmed  and  wiped  dry,  when 
it  is  ready  for  use. 

When  gutta  percha  remains  a  long  time  exposed  to  the  air,  it 
gradually  oxidizes,  its  color  becomes  darker,  it  loses  its  tenacity  and 
flexibility.  This  may  be  prevented  by  keeping  it  constantly  immersed 
in  cold  water. 

The  same  objection  has  been  made  also  to  gutta  percha  which  is 
occasionally  made  to  felt,  namely,  that  it  confines  the  perspiration,  but 
to  this  we  have  already  sufficiently  replied. 

There  is  scarcely  any  fracture  demanding  the  use  of  a  splint  in 
which  I  have  not  demonstrated  its  utility,  but  it  is  especially  valuable, 
as  I  shall  have  occasion  to  mention  again,  as  an  interdental  splint  in 
fractures  of  the  jaw,  and  as  a  moulding  tablet  in  all  fractures  occur- 
ring in  the  vicinity  of  joints. 

Sheets  of  gutta  percha  of  any  required  thickness  may  be  obtained 
in  this  city,  of  Mr.  Samuel  C.  Bishop,  the  manufacturer,  at  113  Liberty 
Street.     One  pound  will  make  about  four  thigh-splints. 

Benjamin  Welch,  of  Lakeville,  Conn.,  has  contrived  a  very  ingenious 
application  of  gutta  percha  to  the  purposes  of  a  splint,  by  veneering 
a  thin  plate  of  the  gum  with  equally  thin  plates  of  elastic  wood.  The 
veneering  is  laid  upon  both  sides,  and  then  it  is  pressed  into  form  in 
moulds.  The  elasticity  of  the  wood,  together  with  the  plasticity  of 
the  gum,  enables  the  surgeon  to  change  its  form  somewhat  at  pleasure, 
by  dipping  it  into  hot  water.  Its  form  cannot,  however,  be  changed 
to  any  great  extent,  and  by  frequent  immersion  in  hot  water  the  ve- 
neering is  apt  to  loosen  from  the  gutta  percha.  Nevertheless,  it  is  a 
most  excellent  splint,  and  in  very  many  respects  it  is  superior  to  any 
of  the  carved  wooden  splints  which  we  have  ever  seen. 


54 


GENEEAL  TREATMENT  OF  FRACTURES. 


Fig.  10.  The  moulding  tablet  of  Alfred  Smee, 

composed  of  gum  Arabic  and  whiting, 
spread  upon  cloth/  has  nothing  special 
to  recommend  it,  any  more  than  the 
cloth  splints,  hardened  with  the  whites 
of  eggs  and  flour,  used  by  Larrey.^ 
Starch  and  alum,  glue,  pitch,  and  vari- 
ous other  materials  of  a  similar  character 
deserve  only  to  be  mentioned  as  having 
been  occasionally  employed,  but  which 
have  never  succeeded  in  securing  for 
themselves  the  confidence  of  surgeons. 

In  1834,  Seutin,  of  Brussels,  intro- 
duced the  use  of  starch  as  a  means  of 
hardening  the  bandages;  his  method  of 
using  which  is  essentially  as  follows  :  a 
dry  roller  is  first  applied  to  the  skin, 
and  then  smeared  with  starch  ;  all  of 
the  bony  prominences  and  irregularities 
of  the  limb  are  filled  up  or  covered  with 
cotton  batting,  charpie,  down,  etc.;  strips 
of  pasteboard,  or  of  binders'  board, 
moistened  and  covered  also  with  starch, 
are  now  laid  alongside  the  limb,  over 
which  again  are  turned  in  succession 
one,  two,  or  three  layers  of  the  starched 
roller ;  the  number  of  rollers  and  the 
thickness  of  the  pasteboard  being  proportioned  to  the  size  of  the  limb 
or  to  the  required  strength  of  the  splint.  The  whole  is  completed  by 
starching  the  outside  of  the  last  bandage. 

This  dressing  will  generally  become  dry  within  from  thirty  to  forty 
hours;  which  process  may  be  expedited  by  exposing  its  sides  as  much 
as  possible  to  the  air,  or  by  the  application  of  artificial  heat  with  bags 
of  dry  sand,  or  with  hot  bricks.  As  a  temporary  support  until  the 
drying  is  completed,  some  surgeons  lay  upon  each  side  of  the  limb 
additional  splints,  securing  them  in  place  with  tapes. 

As  soon  as  the  bandages  are  dry,  they  are  to  be  cut  along  the  front 
to  a  sufiicient  extent  to  permit  of  an  examination  of  the  limb,  and  then 
closed  with  an  additional  roller.  For  the  purpose  of  opening  the 
bandages  both  at  this  period  and  subsequently,  Seutin  uses  a  pair  of 
strong  scissors  or  pliers,  such  as  are  represented  in  Fig.  11. 

On  the  third  or  fourth  day,  or  as  soon  as  the  subsidence  of  the  swell- 
ing may  render  it  necessary,  the  bandages  should  be  cut  open  through 
their  whole  extent,  the  edges  pared  off  and  brought  together  again 
snugly  with  an  additional  roller. 


Sfarcli  bandages,  applied  for  a  broken 
thigb. 


'  Amer.  Joiirn.  Med.  Sci.,  vol.  xxvi.  p.  220,  May,  1840;  from  London  Lancet, 
Jan.  25,  1840. 

2  Amer.  Journ.  Med.  Sci.,  vol.  ii.  p.  216,  May,  1828  ;  from  Journal  des  Progers, 
vol.  iv. 


GENERAL    TREATMENT    OF    FRACTURES.  55 

Fig.  11. 


Sentin's  pliers. 

Erichsen,  who  uses  the  starch  bandage  in  all  fractures  and  from  the 
first  day,  advises  that  the  limb  shall  be  completely  enveloped  with 
cotton  wadding  before  the  first  roller  is  applied  ;  in  consequence  of 
which,  he  does  not  think  it  necessary  to  apply  the  first  roller  dry, 

Velpeau  prefers  dextrine  ("  British  gum"),  a  kind  of  glue  or  jelly 
obtained  by  the  continued  action  of  diluted  sulphuric  acid  upon  starch 
at  the  boiling  point.  It  is  prepared  for  use  by  dissolving  it  in  alcohol 
or  tincture  of  camphor,  or  camphorated  brandy,  until  it  has  acquired 
about  the  consistence  of  honey;  at  this  point  hot  water  should  be 
added,  reducing  its  consistence  to  that  of  thin  treacle,  when,  after  one 
or  two  minutes'  shaking,  it  is  ready  for  application.  According  to  F. 
D'Arcet,  the  proportions  most  favorable  to  the  drying  and  solidifying 
of  the  apparatus  are,  one  hundred  parts  of  dextrine,  sixty  of  cam- 
phorated brandy,  and  fifty  of  water.  Malgaigne,  to  whom  I  am  in- 
debted for  this  observation  of  D'Arcet,  says,  also,  in  a  note,  "  as  regards 
dextrine,  an  important  point  was  recently  brought  practically  under 
my  notice,  viz.,  that  as  sold  in  the  shops,  it  is  often  unfit  for  making 
an  agglutinative  mixture;  it  forms  lumps  with  alcohol,  as  starch  does 
with  cold  water,  without  cohering;  and  twice  in  succession  I  have 
been  obliged  to  change  the  supply  at  the  Hopital  Saint  Antoine.  The 
dextrine  thus  deteriorated  is  whiter  and  less  saccharine ;  it  crepitates 
more  in  the  fingers  ;  and  on  pouring  a  few  drops  of  tincture  of  iodine 
into  the  solution,  there  is  produced  a  violet  tint,  indicating  the  pre- 
sence of  fecula;  while  true  dextrine,  treated  with  iodine,  gives  a 
vinous  red,  or  the  color  of  onion-peel." 

Velpeau  soaks  his  bandages  with  the  dextrine  before  applying 
them,  but,  like  Seutin,  he  applies  his  first  roller  dry.  He  uses  but  one 
bandage,  which  he  carries  first  from  below  upwards,  and  then  from 
above  downwards;  and  he  rarely  thinks  it  necessary  to  employ  the 
pasteboard  as  a  collateral  support. 

For  myself,  I  am  quite  as  much  in  the  habit  of  using  wheat  flour 
paste  as  either  starch  or  dextrine,  and,  if  properly  made,  it  dries  about 
as  quickly  as  the  starch,  and  is  equally  as  firm. 

Whatever  material  is  used  in  the  construction  of  what  is  now  usually 
termed  the  "  immovable  apparatus,"  or,  as  Seutin  has  more  lately  called 
it,  the  "  movable  immovable  apparatus"  ("  movo-amobile"),  in  reference 
to  his  practice  of  opening  it  at  an  early  period,  it  is  still  the  same 
apparatus  in  effect,  and  is  liable  to  the  same  judgment — a  judgment 
which  we  shall  find  it  very  difficult  to  declare,  since,  from  the  day  in 
which  this  practice  was  first  recommended  by  Seutin,  to  the  present 
moment,  it  has  been  constantly  experiencing  the  most  extraordinary 


56 


GEXEEAL  TREATMENT  OF  FEACTURES. 


vicissitudes  in  the  public  favor.  At  one  time,  and  by  the  most  ex- 
perienced surgeons,  extolled  as  a  method  unequalled  in  its  simplicity, 
efficiency,  and  safety;  and  at  another,  and  by  surgeons  of  equal  expe- 
rience, denounced  as  eminently  lacking  in  all  of  the  true  essentials  of 
an  apparatus  for  broken  limbs.  These  conflicting  opinions,  which  it 
is  impossible  to  reconcile,  have  nevertheless  some  foundation  in  truth. 
The  immovable  apparatus,  of  whatever  materials  constructed,  is  under 
some  circumstances  a  very  simple,  safe,  and  efficient  dressing,  while 
under  other  circumstances  it  is,  as  we  think,  eminently  unsafe  and 
inefficient.  Thus,  in  all  of  those  fractures  which  are  accompanied 
with  such  injury  to  the  soft  parts  as  to  render  subsequent  inflamma- 
tion inevitable  or  probable,  this  form  of  dressing  exposes  to  conges- 
tion, strangulation,  and  gangrene.  Whatever  its  advocates  may  say 
to  the  contrary,  the  simple  fact  is  before  us,  that  the  number  of  acci- 
dents resulting  from  this  practice  is  out  of  all  proportion  with  any 
other  yet  introduced.  I  have  met  with  them  myself  in  all  parts  of 
my  own  country,  and  the  journals  abound  with  records  of  disasters 
from  this  source.'  Nor  is  it  a  sufficient  reply  to  this  statement,  that, 
with  proper  care  and  prudence,  such  accidents  may  be  avoided.  We 
think  they  could  not  always  be  avoided.  But  admitting  that  they 
could,  it  is  still  undeniable  that  in  certain  cases  the  immovable  appa- 
ratus demands  extraordinary  attention  ;  and  what  is  the  need  of  multi- 
plying our  cares  when  already  they  are  more  than  sufficient  ?  Many 
circumstances,  over  which  he  has  no  control,  may  prevent  the  surgeon 
from  giving  to  the  limb  the  full  amount  of  attention  which  is  required; 
and  for  this  reason  that  apparatus  is  the  best  which,  whilst  it  answers 
the  indications  equally  well,  exacts  the  least  amount  of  skill  and 
attention  on  the  part  of  the  surgeon. 


Fiff.  12. 


Opening  of  the  apparatus  with  Seutin's  pliers. 

Immovable  dressings  are  not  only  liable  to  become  too  tight  as  the 
swelling  augments,  but,  on  the  other  hand,  the  surgeon  may  omit  to 
notice  that  as  the  swelling  has  subsided  it  has  become  loose.  Portions 
of  the  limb  may  vesicate,  ulcerate,  or  even  slough,  without  the  know- 
ledge of  the  surgeon.    If,  however,  the  bandages  are  frequently  opened, 

'  Amer.  Joum.  Med.  Sci.,  vol.  xxv.  p.  460,  Feb.  1840  ;  also  yoI.  xxxi.  p.  212. 


GENERAL  TREATMENT  OF  FRACTURES. 


57 


Fiff.  U 


and  all  the  proper  precautions  are  taken,  it  is  possible  that  these  acci- 
dents may  also  be  avoided  ;  but  unfortunately  experience  has  shown 
that  they  have  not  been  avoided  in  too  many  instances. 

The  cases,  then,  to  which  this  apparatus  seems  to  be  adapted,  are  a 
few  examples  of  transverse  or  serrated  fractures  in  which  the  bones 
have  not  become  displaced,  and  in  which  little  or  no  swelling  is  anti- 
cipated ;  and  certain  fractures  which  were  oi'igi- 
nally  more  complicated,  but  in  which  a  partial 
union,  and  the  subsidence  of  the  inflammation, 
have  reduced  them  to  a  more  simple  condition; 
and  especially  is  it  adapted  to  cases  of  delayed 
union.  If  now  the  dressings  are  applied  care- 
fully, the  bandage  being  only  moderately  tight; 
and  a  portion  of  the  extremity  of  the  limb  is 
left  uncovered  so  that  we  may  observe  con- 
stantly its  condition,  and  at  proper  intervals  the 
apparatus  is  opened  completely,  in  order  that 
we  may  subject  the  whole  limb  to  a  thorough 
examination;  in  such  cases  as  we  have  now 
indicated,  and  with  such  precautions,  we  admit 
that  the  "  apparatus  immobile"  constitutes  an 
invaluable  surgical  appliance,  and  one  of  which 
no  surgeon  can  well  aftbrd  to  be  deprived. 

I  have  even  met  with  examples  of  compound 
fractures  in  which  it  has  seemed  proper  to  ap- 
ply this  dressing;  and  especially  when  a  suffi- 
cient time  had  elapsed  to  render  it  probable  that 
there  would  be  no  sudden  accession  of  swelling 
in  the  limb.  In  such  cases  I  have  preferred 
generally  to  lay  the  several  turns  of  the  roller 
directly  over   the   suppurating  wound  in  the 

same  manner  as  if  no  wound  existed,  and  to  make  a  valvular  opening, 
or  window,  with  the  scissors  on  the  following  day,  in  order  to  allow 
the  matter  to  escape,  after  which  the  valve  may  be  laid  down  and 
stitched,  or  the  piece  may  be  removed  entirely,  and  a  new  piece  of 
bandage  drawn  closely  around  the  limb  at  this  point.  This  may  be 
repeated  once  or  twice  daily.  If  an  opening  is  left  by  the  roller, 
and  no  additional  bandage  is  laid  over  it,  the  margins  of  the  wound 
soon  become  cedematous  and  protrude,  making  an  ugly-looking  and 
ill-conditioned  sore. 

Plaster  of  Paris  moulds,  employed  occasionally  from  a  very  early 
period,  and  more  lately  recommended  by  Hendriksz,  Hubenthal,  Keyl, 
and  Dieft'enbach^  are  not  entitled  to  serious  consideration.  Heavy  stone 
coffins,  they  might  serve  well  enough  the  purposes  of  interment,  but 
they  are  wholly  unsuited  to  the  purposes  of  a  splint. 

Plaster  of  Paris  has,  however,  been  of  late  employed  in  another 
form,  and  in  relation  to  which  our  judgment  must  be  much  more 
favorable.  I  allude  to  the  so-called  "  plaster  of  Paris  bandages."  which 
were  first  introduced  to  notice  by  Mathiesen  and  Van  der  Loo,  of 
Holland,  but  the  value  of  which  has  been  more  especially  brought  to 
5 


"Apparatus  immobile"  ap- 
plied over  a  compound  frac- 
ture. 


58  GENEEAL    TREATMENT    OF    FEACTTJRES. 

notice  by  Prof.  Nicholas  Pirogoff,  of  St.  Petersburg,  Surgeon-in-chief 
at  Sebastopol,  during  the  Crimean  war. 

At  Bellevue,  during  the  last  two  or  three  years,  plaster  of  Paris 
bandages  have  been  used  quite  extensively,  and,  after  a  careful  ob- 
servation of  the  results  in  my  own  wards  and  in  the  wards  of  my 
colleagues,  I  find  no  occasion  to  recall  anything  I  have  said  of  this,  as 
one  form  of  the  immovable  apparatus,  in  the  preceding  pages ;  the 
dangers  have  not  been  overestimated,  yet  I  must  say  that  in  fractures 
of  the  leg,  whether  simple  or  compound,  when  great  care  is  exer- 
cised in  the  management  of  the  case,  it  is  in  several  respects  superior 
to  any  other  form  of  dressing.  I  shall  describe  the  cases  of  fracture 
of  the  leg  to  which  it  is  applicable  more  particularly  when  speaking 
of  these  fractures.  I  am  not  at  present,  however,  prepared  to  speak 
of  it  so  favorably  in  the  fractures  of  any  other  long  bones. 

The  manner  of  using  gypsum  bandages  generally  preferred  at 
Bellevue  Hospital,  may  be  thus  briefly  described.  Thin,  rather  coarse 
unglazed  cotton  cloth,  torn  into  strips,  is  laid  upon  a  table  and  the 
dry  plaster  rubbed  into  it  until  its  meshes  are  full.  It  is  then  rolled 
and  made  ready  for  use  by  immersing  it  a  few  minutes  in  hot  water. 
The  limb,  being  held  in  a  proper  position,  is  first  inclosed  in  soft  dry 
flannel  cloth,  and  the  rollers  are  then  applied.  In  most  cases  two  or 
three  thicknesses  of  bandage  are  found  to  be  sufficient. 

Another  method  of  using  the  gysum  bandages  is  as  follows :  A  dry 
roller  is  first  applied  to  the  limb,  or  it  may  be  covered  with  a  single 
piece  of  cloth  of  any  kind,  and  the  irregularities  are  filled  up  and  pro- 
tected with  cotton-wool,  the  same  as  we  have  directed  when  about  to 
apply  the  starch  bandage.  The  remaining  dressings  being  now  at 
hand  and  ready  for  use,  we  proceed  to  mix  the  plaster.  For  this  pur- 
pose we  must  select  the  fine,  fresh,  well-dried,  white  powder.  The 
gray  does  not  solidify  well,  nor  that  which  has  been  a  long  time 
ground,  or  is  moist.  The  proportions  of  water  and  plaster  usually 
required  are  about  equal  parts  by  weight.  For  the  thigh  it  may  re- 
quire, perhaps,  seven  or  eight  pounds  of  plaster,  and  for  the  leg  or  arm 
much  less.  It  is  probably  a  better  rule  to  direct  the  gypsum  to  be 
added  to  the  water  until  it  is  of  about  the  consistence  of  cream.  The 
water  should  be  cold  and  the  gypsum  thrown  in  not  too  rapidly,  at 
least  not  more  rapidly  than  it  can  be  thoroughly  mixed,  otherwise  we 
shall  not  be  able  to  determine  precisely  its  consistence.  If,  while  ap- 
plying the  paste,  it  begins  to  harden  in  the  bowl,  we  must  not  add  more 
water,  as  this  will  again  interfere  with  its  final  solidification  upon  the 
limb.  It  must  be  thrown  away  and  som.e  fresh  immediately  prepared  ; 
or  the  crystallization  may  be  retarded  by  throwing  in  a  few  drops  of 
carpenters'  glue,  or  a  little  starch  or  dextrine;  but  the  plaster  is  apt 
to  be  brittle  after  the  addition  of  these  articles.  The  solidification 
may  be  hastened  by  adding  a  little  salt  to  the  water.  When  the 
plaster  is  good,  and  it  is  properly  mixed,  we  may  allow  ourselves  from 
five  to  eight  minutes  in  the  application.  A  large  paint-brush  is  the 
most  convenient  thing  for  spreading  it,  but  the  hands  will  do  very 
well  in  an  emergency. 

Everything  being  ready,  the  limb  is  to  be  seized  by  assistants  at 


GEXERAL  TREATMENT  OF  FRACTURES.         59 

both  of  its  extremities  and  held  in  a  position  of  steady  extension  until 
the  dressing  is  completed,  and  for  one  or  two  minutes  longer,  or  until 
the  plaster  is  hard.  It  will  be  sufficiently  hard  to  support  itself,  even 
when  the  dressings  are  quite  moist.  The  surgeon  then  proceeds  to  lay 
a  long  piece  of  linen — old  sack  will  answer  as  well  as  any — folded 
three  or  four  times,  and  saturated  with  the  paste,  parallel  to  the  two 
sides  of  the  limb,  around  which  are  to  be  immediately  placed,  horizon- 
tally and  at  several  points,  short  and  wide  strips  of  the  same  material. 
These  latter  are  intended  to  increase  the  strength  of  the  apparatus,  and 
to  bind  on  the  side  strips.  Finally,  the  whole  may  be  painted  with 
the  solution.  It  is  very  well,  however,  not  to  cover  the  front  of  the 
limb,  or  a  narrow  strip  somewhere  in  the  line  of  the  axis  of  the  limb, 
with  the  plaster,  as  this  will  not  diminish  materially  its  strength,  and 
it  will  enable  the  surgeon  to  open  it  more  easily  with  the  scissors. 
Pirogoff  accomplishes  the  same  purpose  by  laying  a  piece  of  narrow 
tape,  soaked  in  oil,  along  the  line  through  which  he  wishes  to  make 
the  section  of  the  splint.' 

At  Bellevue  Hospital  we  also  occasionally  apply  the  plaster  of  Paris 
by  a  method  which  is  very  simple.  The  limb  being  carefully  shaven, 
is  enveloped  with  one  single  sheet  of  coarse  woollen  cloth,  which  is 
previously  thoroughly  saturated  with  the  plaster. 

Dr.  E.  Harris,  of  this  city,  has  ascertained  that  by  mixing  the  plaster 
in  the  following  proportions  the  weight  will  be  considerably  dimin- 
ished, namely,  water  100  parts  by  weight,  gypsum  75  parts,  clear- 
boiled  starch  2  parts.  By  this  method  the  process  of  crystallization 
is  retarded,  and  all  the  water,  except  about  twenty  per  cent.,  is  per- 
mitted to  escape.  For  the  use  of  the  surgeons  in  the  U.  S.  Army,  the 
Sanitary  Commission  furnished  the  plaster  in  tin  cans  hermetically 
sealed.^ 

Professor  B.  W.  Dudley,  of  Lexington  Ky.,  one  of  the  most  success- 
ful surgeons  in  this  country,  but  especially  distinguished  as  a  lithoto- 
mist,  for  many  years  employed  in  the  treatment  of  fractures  nothing 
but  a  roller,  regarding  both  side-splints  and  extending  apparatus  as 
not  only  useless,  but  absolutely  pernicious.'  This  practice,  which 
seems  to  have  originated  with  Radley,  of  England,  has  not  found, 
hitherto,  in  this  country  or  elsewhere,  many  imitators. 

Still  more  unscientific  and  irrational  was  the  practice  of  Jobert, 
of  Paris,  who  employed  neither  side-splints  nor  bandages,  but  only 
extension,  in  the  treatment  of  all,  or  of  nearly  all  fractures  of  the  long 
bones.  The  side  or  coaptation  splints  bring  the  fragments  into  more 
complete  apposition,  and  secure  a  more  prompt  and  certain  union. 
They  ought,  therefore,  never  to  be  omitted,  unless  the  condition  of  the 
limb  precludes  their  application. 

As  to  the  question  of  permanent  extension  in  fractures,  and  the 

'  Weber  on  Plaster  of  Paris  Bandage,  New  York  Journ.  Med.,  May,  1856,  p.  341. 

2  Practical  Lectures  on  Military  Surgery,  by  Isidor  Gliick,  of  New  York,  chief 
surgeon  to  the  Hungarian  (Vilmos)  Hussars,  &c.  &c.,  during  the  late  war  in  Hun- 
gary. Araer.  Med.  Monthly,  Dec.  1855,  p.  449,  &c.,  vol.  iv.  New  York  Med. 
Times,  Dec.  7,  1861. 

'^  Dudley,  Trans.  Amer.  Med.  Assoc.,  vol.  iii.,  1850,  p.  349. 


60         GENERAL  TREATMENT  OF  FRACTURES. 

means  by  which  it  may  be  most  effectually  accomplished,  nothing 
need  be  said  at  this  time,  inasmuch  as  it  relates  only  to  the  fractures 
of  certain  bones,  and  to  certain  forms  of  fractures;  we  must  therefore 
refer  its  consideration  to  those  chapters  which  treat  of  individual 
bones. 

In  the  treatment  of  comminuted  fractures,  no  pains  ought  to  be 
spared  to  bring  the  fragments  as  nearly  as  possible  into  apposition  ; 
and  if  there  exists  at  the  same  time  an  external  wound,  and  the  frag- 
ments are  small  and  loose,  they  ought  to  be  removed  carefully.  Nor, 
indeed,  should  we  be  deterred  from  the  attempt  to  remove  them  by 
finding  that  they  are  somewhat  adherent,  if  still  they  are  very  easily 
moved  about  with  the  finger. 

In  comi:)Ound  fractures,  not  unfrequently  the  end  of  one  of  the  frag- 
ments protrudes  from  the  wound,  and  its  reduction  may  be  attended 
with  considerable  dijBficulty.  My  practice  is  usually  in  such  cases  to 
attempt  the  reduction  first,  by  simple  extension  and  counter-exten- 
sion ;  but  if  this  fails,  I  introduce  my  finger  into  the  wound,  and 
endeavor  to  stretch  the  skin  over  the  sharp  point  of  bone  ;  or  I  make 
use  of  a  spatula  formed  from  a  piece  of  shingle,  or  of  any  suitable 
piece  of  metal  which  may  be  at  hand ;  finally,  but  not  until  all  other 
expedients  have  failed,  I  enlarge  the  wound  sufficiently  to  insure  its 
return. 

There  are  some  cases,  however,  in  which  the  surgeon  may  feel 
justified  in  sawing  off  the  projecting  end;  as  when  the  periosteum  is 
completely  torn  from  it  by  its  having  penetrated  a  boot,  or  even  some- 
times when  its  extremity  is  very  sharp,  and  there  is  reason  to  suppose 
that  it  would  prick  and  irritate  the  tissues.  In  these  cases,  also,  sur- 
geons have  proposed  to  secure  the  fragments  in  apposition  by  metallic 
ligatures  or  sutures.  In  a  few  instances  the  practice  has  been  attended 
with  success,  but  in  most  cases  the  wires  have  failed  utterly  of  their 
purpose,  and  have  only  proved  sources  of  additional  irritation. 

If  arteries  bleed  freely  and  for  a  long  time,  we  may  make  some 
effort  to  find  the  open  mouths  in  the  wound ;  but  in  this  we  rarely 
succeed,  nor  is  it  prudent  always  to  tie  the  main  branch  which  supplies 
the  limb.  Fortunately,  this  bleeding,  although  at  first  profuse,  gene- 
rally ceases  in  a  few  hours  under  the  steady  employment  of  cold  lotions, 
moderate  compression,  and  rest.  If  it  does  not,  the  chances  are  that 
the  case  will  call  for  amputation. 

The  rule  generally  laid  down  by  surgeons,  that  we  should  at  once 
close  the  wound  in  compound  fractures,  with  sutures  and  adhesive 
straps  if  necessary,  or  with  bandages,  is  far  too  absolute.  This  prac- 
tice will  do  when  there  is  no  great  contusion  or  extravasation  of  blood; 
but  if  blood  is  flowing,  it  is  much  better  to  leave  the  wound  open,  so 
as  to  permit  it  to  escape  freely  ;  and  if  the  severity  of  the  injury  war- 
rants the  supposition  that  much  inflammation  is  to  ensue,  the  danger 
of  gangrene  is  greatly  lessened  by  thus  allowing  the  opening  to  remain 
as  a  channel  of  exit  for  the  inflammatory  effusions. 

It  has,  however,  been  claimed  of  late  by  Mr.  Lister,  of  Edinburgh, 
and  by  many  others  who  have  adopted  his  practice,  that  by  the  use 


GENERAL  TREATMENT  OF  FRACTURES.         61 

of  carbolic  acid  in  the  manner  which  will  presently  be  described,  we 
may  again  return  safely  to  the  old  practice  of  closing  at  once  all 
wounds  connected  with  fractures,  without  regard  to  the  degree  of 
contusion,  laceration,  or  comminution ;  indeed,  it  is  affirmed  that  by 
the  adoption  of  this  method  of  treatment  we  may  avoid  suppuration 
and  its  consequences  in  a  very  large  proportion  of  cases.  It  is  be- 
lieved by  Mr.  Lister  that  suppuration  is  mainly  due  to  the  presence  of 
certain  germs  which  constantly  float  in  the  air,  and  which  carbolic 
acid  is  fully  able  to  destroy.  Every  possible  precaution  is  therefore 
taken  to  exclude  the  air,  and  to  disinfect  that  which  is  unavoidably 
brought  in  contact  with  the  wound.  The  interior  of  the  fresh  wound 
is  fully  injected  with  carbolic  acid  of  the  strength  of  one  part  of  car- 
bolic acid  to  twenty  of  water ;  nor  does  he  hesitate  to  throw  this  into 
wounds  communicating  with  joints.  The  fluid  being  afterwards 
carefully  expressed,  the  surface  of  the  wound  is  covered  first  by  the 
"  protective,"  which  is  a  piece  of  oiled  silk  coated  with  a  thin  layer  of 
a  mixture  composed  of  one  part  of  dextrine,  two  of  powdered  starch, 
and  sixteen  of  a  cold  solution  of  carbolic  acid ;  the  latter  being  of  the 
same  strength  as  the  solution  employed  for  injecting  the  wound. 
Over  this  Mr.  Lister's  lac  plaster  is  applied,  surrounding  the  entire 
limb  and  extending  several  inches  above  and  below  the  wound.  Dr. 
A.  R.  Strachan,  of  this  city,  who  has  been  kind  enough  to  furnish  me 
with  these  details,  taken  from  his  own  notes  as  they  were  made  under 
Mr.  Lister's  instructions,  is  unable  to  give  me  the  formula  for  the  lac 
plaster.  At  Bellevue  we  use  a  lac  composed  of  gum  shellac  three 
parts,  and  carbolic  acid  crystals  one  part ;  the  shellac  being  stirred 
in  gradually  while  the  crystals  are  heated  nearly  to  the  boiling  point. 

The  subsequent  dressings  must  be  made  as  often  as  the  character 
and  amount  of  the  discharge  may  seem  to  require ;  but  at  each  dress- 
ing care  must  be  taken  not  to  admit  the  air  to  the  surface  of  the 
wound;  and  for  this  purpose  Mr.  Lister  conducts  the  changes  in  the 
dressings  under  a  stream  of  the  watery  solution  of  the  carbolic  acid, 
which  is  continually  playing  upon  the  part. 

Many  years  since,  Dr.  J.  Rhea  Barton  introduced  into  the  Pennsyl- 
vania Hospital  what  has  since  been  called  the  "  bran  dressing"  for  the 
treatment  of  compound  fractures  of  the  leg ;  the  limb  being  made  to 
repose  in  a  box  filled  with  this  material.^  I  have  used  it  very  fre- 
quently in  Bellevue  and  in  other  hospitals,  and  can  speak  of  it  as 
possessing  many  qualities  of  excellence,  especially  as  a  summer  dress- 
ing. The  particular  mode  of  using  this  apparatus  I  shall  describe 
more  minutely  when  treating  of  fractures  of  the  leg. 

The  treatment  of  inflammatory  symptoms,  and  of  the  later  accidents, 
such  as  suppuration,  oedema,  gangrene,  tetanus,  &c.,  must  be  left  mainly 
to  the  good  judgment  of  the  surgeon.  Gentle  manipulation,  uniform 
support,  rest,  and  sometimes  cooling  lotions  constitute  the  most  impor- 
tant means  by  which  inflammation  is  to  be  controlled.     Bleeding  is 

'  Paper  on  Bran  Dressing,  by  Reynell  Coates,  of  Philadelphia.  Amer.  Journ. 
Med.  Sci.,  April,  1843,  p.  515;   from  the  Med.  Examiner,  Nos.  9  and  11,  vol.  i., 

New  Series. 


\ 


62  DELAYED    AND    NON-UNION    OF    BROKEN    BONES. 

rarely  necessary,  and  in  a  large  majority  of  cases  it  might  prove 
injurious  by  lowering  too  much  the  vital  forces,  which  need  to  be 
husbanded  in  view  of°the  requirements  of  the  process  of  repair  and  of 
the  long  and  exhausting  confinement.  Cathartics  should  also  be 
administered  cautiously  for  the  same  reason,  and  because  they  are 
liable,  especially  in  fractures  of  the  lower  extremities,  to  occasion  a 
serious  disturbance  of  the  limb. 


CHAPTER    VI. 

DELAYED  UNION,  FIBROUS  UNION,  AND  NON-UNION  OF  BROKEN 

BONES.' 

Most  surgical  writers  concur  in  the  statement  that  non-union  of 
broken  bones  is  an  uncommon  event.  Walker,  of  Oxford,  affirms 
that  of  not  less  than  one  thousand  fractures  which  have  come  under 
bis  treatment  at  some  period  of  the  repair,  he  does  not  recollect  more 
than  six  or  eight  instances.  According  to  Lonsdale,  not  more  than 
five  or  six  cases  of  false  joint,  excepting  those  within  a  capsule,  have 
occurred  out  of  nearly  four  thousand  fractures  treated  at  the  Middle- 
sex Hospital.  In  a  table  of  367  cases,  collected  and  arranged  by  W. 
W.  Morland,  from  the  books  of  the  Massachusetts  General  Hospital, 
extending  through  a  period  of  nineteen  years,  only  one  example  of 
false  joint  is  recorded  ;  but  as  only  seventy-four  days  had  elapsed 
when  this  patient  was  discharged,  it  is  doubtful  whether  this  might 
not  have  proved  to  be  a  case  of  delayed  union  simply.^  In  946  cases 
of  recent  fracture  treated  in  the  Pennsylvania  Hospital,  between  the 
years  1830  and  1840,  there  was  no  instance  of  false  union.^  Sir  Stephen 
Hammick,  Mr.  Liston,  and  Malgaigne  affirm  also  the  infrequency  of 
these  accidents  in  the  cases  which  have  come  under  their  personal 
treatment.  I  have  myself  seen  a  large  number  of  examples  of  non- 
union, but  in  not  one  of  my  own  patients,  whether  in  ho.spital  or 
private  practice,  except,  in  cases  involving  joints,  has  the  bone  re- 
fused finally  to  unite;  and  my  opinion  is,  that,  in  proportion  to  the 
number  of  fractures  everywhere,  these  cases  are  very  rare,  perhaps 
not  in  a  larger  proportion  than  one  in  five  hundred. 

The  humerus  and  femur  would  appear  to  be  the  bones  most  liable 
to  non-union,  as  shown  by  Norris's  statistics ;  in  which  forty-eight  be- 
longed to  the  humerus,  forty-eight  to  the  femur,  thirty-three  to  the  leg, 

'  I  shall  in  this  chapter  avail  myself  freely  of  the  labors  of  George  W.  Norris,  of 
Philadelphia,  whose  paper,  entitled  "On  the  Occurrence  of  Non-union  after  Frac- 
tures, its  Causes  and  Treatment,"  published  in  the  American  Journal  of  tlie  Medical 
Sciences  for  Jan.  1842,  constitutes  the  most  complete  and  reliable  monograph  upon 
this  subject  contained  in  any  language. 

2  Address  on  Fractures,  by  A.  L.  Pierson,  read  before  the  Massachusetts  Med. 
Soc,  May  27,  1840. 

3  Norris,  loc.  cit. 


DELAYED    AND    NON-UNION    OF    BKOKEN    BONES,  63 

nineteen  to  the  forearm,  and  two  to  the  jaw.  In  my  own  experience, 
I  have  found  the  humerus  ununited  much  more  often  than  the  femur. 
B6rard  has  shown  that  in  the  growth  of  the  long  bones  the  period 
at  which  the  epiphyses  are  united  to  the  diaphyses  depends  upon  the 
direction  of  the  nutritive  artery  ;  for  example,  "  it  is  found  that  in  the 
humerus,  where  the  direction  of  this  vessel  is  from  above  downwards, 
consolidation  takes  place  soonest  at  its  inferior  extremity.  In  the  fore- 
arm, the  course  of  the  nutrient  vessels  is  from  below  upwards,  and 
here  consolidation  of  the  epiphyses  is  found  to  occur  at  the  elbow 
sooner  than  at  the  wrist.  In  the  inferior  members,  on  the  contrary, 
the  epiphyses  composing  the  knee  are  the  last  which  become  firm, 
because  in  the  femur  the  nutritious  artery  runs  upwards,  and  in  the 
bones  of  the  leg  it  courses  from  above  downwards."  A  knowledge  of 
these  facts  led  Gueretin  to  inquire  into  the  influence  of  these  arteries 
upon  the  consolidation  of  fractures;  and  the  cases  collected  by  him 
did  indeed  seem  to  show  a  positive  relation  between  the  direction  of 
the  artery  and  the  union  of  the  bone ;  that  is  to  say,  the  examples  of 
non-union  were  chiefly  found  where  the  fracture  had  taken  place  on 
that  side  of  the  nutritious  foramen  from  which  the  artery  entered,  as 
if  to  imply  that  the  non-union  was  in  some  measure  due  to  the  imper- 
fect nutrition  of  this  extremity  of  the  bone.  In  thirty-five  cases  of 
non-union  analyzed  by  Gueretin,  ten  belonged  to  that  portion  of  the 
bone  which  was  traversed  by  the  artery,  and  twenty-five  to  the  other 
portion.  But  an  analysis  of  forty-one  cases,  made  by  Norris,  does  not 
seem  to  confirm  this  observation  of  Gueretin,  since  twenty-seven  were 
in  the  direction  of  the  nutritious  arteries,  and  only  fourteen  in  the' 
opposite  portion,  or  in  that  which  is  supposed  to  be  less  nourished. 

Another  observation,  made  by  Curling,  that  in  fractures  of  the  long 
bones  the  portion  below  the  entrance  of  the  nutrient  artery,  or  on  that 
side  of  the  nutrient  foramen  towards  which  the  blood  flows,  being 
defrauded  of  its  proper  supply,  is  subjected  to  a  species  of  atrophy, 
presenting  a  larger  medullary  canal,  with  thinner  walls,  and  a  spongy 
tissue  less  dense,  also  needs  confirmation.  Malgaigne  has  not  noticed 
this  fact  in  any  of  the  specimens  contained  in  the  public  museums  of 
Paris ;  and  we  do  not  know  that  any  other  writer  has  made  the  ques- 
tion a  subject  of  especial  inquiry. 

According  to  Norris,  there  are  four  principal  kinds  of  false  joint : — 

In  the  first,  the  bones  are  united  and  completely  enveloped  in  a  car- 
tilaginous mass  or  callous  tumor,  but,  in  consequence  of  some  retarda- 
tion in  the  process,  bony  matter  is  not  deposited,  and,  as  a  consequence, 
it  wants  solidity,  the  part  continuing  easily  movable.  This  may  be 
regarded  as  a  proper  example  of  delayed  union,  as  distinguished  from 
complete  non-union,  or  false  joint. 

In  the  second,  there  is  entire  want  of  union  of  any  sort  between 
the  fragments,  the  ends  of  which  seem  to  be  diminished  in  size  and 
extremely  movable  beneath  the  integuments.  The  limb  in  these  cases 
is  found  wasted  and  powerless. 

In  the  third  and  most  common  class,  the  medullary  canal  is  oblite- 
rated in  both  fragments,  and  the  ends  are  more  or  less  absorbed, 


64  DELAYED    AND    NON-UNION    OF    BROKEN    BONES. 

rounded,  and  covered,  in  part  or  in  whole,  with  a  dense  tissue  resem- 
bling the  periosteum.     A  connection  also  exists  between  the  opposing 

fragments  in  the  form  of  strong  liga- 
Fig.  14.  mentous  or  fibro-ligamentous  bands, 

which,  if  of  any  length,  are  quite 
flexible,  and  allow  of  considerable 
motion  at  the  seat  of  fracture. 

Clavicle  united  byligamentous bands.  j^     ^^^     fourth,_  "  a    dcUSC    Capsule 

without  opening  of  any  kind,  containing  a  fluid  similar  to  synovia,  and 
resembling  closely  the  complete  ligaments,  is  found."  In  ttese  cases 
the  points  of  the  bony  fragments  corresponding  to  each  other  are 
rounded,  smooth,  and  polished,  in  some  instances  ebqrnated,  and  in 
others  covered  with  points  or  even  thin  plates  of  cartilage,  and  a 
membrane  closely  resembling  the  synovial  of  the  natural  articulation. 
It  is  in  this  kind  of  cases,  Norris  remarks,  that  the  member  affected 
may  still  be  of  use  to  the  patient,  the  fragments  being  so  firmly  held 
together  as  to  be  displaced  only  upon  the  application  of  considerable 
force. 

The  existence  of  these  newly-formed  joints,  or  true  diarthroses, 
has  been  called  in  question  by  Boyer,  Hewson,  Chelius,^  and  others  ; 
but  the  observations  of  Sylvestre,  Brodie,  Beclard,  Home,  Howship, 
Otto,  Kuhnholtz,  Houston,  Cooper,  Langenbeck,  and  Breschet  prove 
that  such  examples  are  occasionally  found.^  I  have  myself  met  with 
several  examples. 

A  case  is  reported  as  having  occurred  in  Boston,  Massachusetts,  in 
which  a  young  man,  set.  18,  broke  his  humerus  near  its  middle.  Before 
union  had  been  completed  it  was  accidentally  refractured,  and  from 
this  time  the  fragments  showed  no  disposition  to  unite ;  on  the  con- 
trary, a  gradual  process  of  absorption  took  place,  until  at  length  the 
whole  of  the  humerus  disappeared ;  and  that,  too,  "  without  any  open 
ulcer."  Eighteen  years  later  he  was  perfectly  well,  and  the  arm  was 
strong  and  useful,  but  no  portion  of  the  bone  had  been  reproduced.^ 

Norris  is  a  disciple  of  Dapuytren,  and  accepts  his  doctrine  of  the 
formation  of  callus,  without  reservation ;  consequently  he  finds  no  ne- 
cessity for  but  one  form  of  delayed  union,  namely,  that  which  we  have 
described  as  belonging  to  the  first  class.  In  all  of  this  class  he  assumes 
the  existence  of  a  cartilaginous  ring  or  ferrule ;  but  we  think  the  error 
of  this  exclusive  theory  has  been  sufficiently  shown  by  the  observa- 
tions of  Paget  and  others,  and  we  should  be  warranted  therefore  in 
affirming  the  existence  of  as  many  varieties  of  delayed  union  as  there 
are  varieties  in  the  manner  and  position  of  the  deposit  of  callus,  even 

•  Malad.  Chirurg.,  t.  iii.  p.  103,  Paris,  1831 ;  North  Amer.  Med.  and  Surg. 
Journ.,  No.  ix.  p.  7,  1828 ;  Trait,  de  Cliir.,  trad,  par  Pigne,  p.  150,  1836.  (Norris, 
loc.  cit.) 

2  Nouvelles  dela  Repub.  des  Lettres  de  Bayle,  p.  718, 1685  ;  Lond.  Med.  Gaz.,  xiii. 
p.  57, 1883  ;  Beclard,  Gen.  Anat.,  trans,  by  Hay  ward,  pp.  149,  348  ;  Transac.  Med.- 
Chir.  Soc.  of  Edinburgh,  i.  p.  233,  1793  ;  Med.-Chir.  Trans.,  viii.  p.  517, 1817  ;  Otto's 
Path.  Anat.,  trans,  by  South,  i.  p.  138;  Journ.  Complement.,  iii.  p.  391  ;  Dub. 
Med.  Journ.,  viii.  p.  493  ;  Cooper  on  Frac.  and  Disloc,  fourth  London  ed.,  p.  508; 
Recherch.  sur  les  Formation  du  Cal,  1819,  p.  34.     (Norris,  loc.  cit.) 

*  Boston  Med.  and  Surg.  Journ.,  July  11,  1868,  p.  368. 


DELAYED    AND    NON-UNION    OF    BROKEN    BONES.  65 

if  their  actual  existence  had  not  been  repeatedly  demonstrated  by 
dissections. 

The  causes  of  delayed  union  and  of  non-union  are  either  constitu- 
tional or  local. 

The  constitutional  causes  are  chiefly  those  conditions  of  the  general 
system  which  manifest  themselves  by  anaemia,  debility,  or  some  pecu- 
liar dyscrasy. 

Sanson,  Beulac,  Condie,^  and  many  others  have  mentioned  cases  in 
which  the  existence  of  syphilis  in  the  system  has  seemed  to  prevent 
the  formation  of  callus;  but,  on  the  other  hand,  Lagneau  and  Oppen- 
heim^  incline  to  the  opinion  that  syphilis  exerts  in  this  respect  but 
little  influence;  and  even  Bdrard,  who  admits  the  pertinence  of  one 
case  observed  by  Nicod,  concludes,  after  numerous  researches,  that  it 
has  been  very  rarely  shown  to  affect  the  formation  of  callus.^ 

Pregnancy  and  lactation  have  been  known  to  interfere  with  the  union 
of  bones.  Werner,  Hildanus,  Wilson,  Hertodius,  Alanson,  Bard,  of 
New  York,  and  Condie,  of  Philadelphia,*  have  all  reported  examples, 
in  some  of  which  the  process  of  union  was  resumed  and  brought  to  a 
rapid  completion  so  soon  as  the  period  of  pregnancy  was  closed,  or 
when  lactation  ceased ;  but  three  cases  reported  by  Sir  Stephen  Love 
Hammick  would  seem  to  show,  what,  indeed,  other  evidences  render 
probable,  that  the  delay  was  less  due  to  the  fact  of  the  pregnancy  and 
the  lactation  than  to  the  debility  occasionally  consequent  upon  these 
conditions.* 

As  to  the  question  whether  cancer  ever  causes  a  delay  in  the  union 
of  bones,  it  may  be  said  that  where  the  fracture  arises  in  consequence 
of  a  true  cancerous  deposit  around  or  in  the  interior  of  the  bones, 
producing  absorption  of  their  tissue,  no  union  takes  place ;  but  that 
the  mere  presence  of  the  cancerous  cachexy  does  not  usually  prevent 
the  formation  of  callus. 

Scurvy,  fevers  of  a  low  type,  and,  on  the  other  hand,  fevers  of  a 
highly  inflammatory  character,  profuse  uterine  and  vaginal  discharges, 
and  rachitis,  conduce  to  the  same  result. 

The  withdrawal  of  a  habitual  stimulus,  and  especially  a  change 
from  a  good  to  a  low  diet,  or  copious  bleedings,  may  either  of  them 
delay  the  deposit  of  ossific  matter,  or  prevent  it  altogether.* 

Bonn  has  furnished  two  cases  in  which  advanced  age  seemed  to 
have  retarded  the  formation  of  callus,  but  Horner  saw  a  fracture  of  the 
humerus  in  a  woman  ninety  years  old  unite  in  five  weeks.^  I  have 
myself  noticed  a  good  many  similar  examples  in  advanced  life,  and 
it  is  now  rendered  quite  probable  that  surgeons  have  generally  over- 
estimated the  influence  of  age  upon  the  formation  of  callus. 

»  Diet,  de  Med.  et  Chir.  Prat.,  iii.  p.  492  ;  Journ.  de  Med.  Chir.  et  Pharm.,  t.  xxv. 
p.  216.     (Norris,  loc.  cit.) 

2  Expose  des  symp.  de  la  mal.  Yen.,  p.  525 ;  Oppenheim  on  False  Joints,  1837. 
(Norris,  loc.  cit.) 

3  Op.  cit.,  p.  21. 

4  Cooper's  Die.,  ed.  1838,  p.  546  ;  Opera  Hild.,  1681  ;  Wilson  on  the  Human 
Skeleton,  p.  214;  Bib.  Choisie  de  Med.,  xxiv.  p.  595 ;  Med.  Obs.  and  Inquiries,  4, 
1772 ;  Philosoph.  Trans.,  xlvi.  p  397,  1750.     (Norris,  loc.  cit.) 

5  Practical  Remarks  on  Amputations,  Fractures,  &c.,  p.  121.     (Norris,  loc.  cit.) 
8  Korris,  loc.  cit.  ?  Ibid.,  p.  29. 


6Q  DELAYED    AND    NON-UNION    OF    BROKEN    BONES. 

The  local  causes  are,  arrest  of  the  arterial  circulation  by  bandages, 
paralysis  or  impairment  of  the  nervous  circulation,  the  occurrence  of 
the  fracture  within  a  capsule,  obliquity  of  the  fracture,  overlapping 
of  the  fragments,  interposition  of  a  piece  of  bone,  of  a  tendon,  mus- 
cle, or  of  a  clot  of  blood,  or  separation  of  the  fragments  from  any 
cause  whatever,  erysipelas,  acute  phlegmonous  inflammation,  suppura- 
tion, necrosis,  too  much  motion,  exclusion  of  light  and  air  inducing 
local  scurvy,  wet  and  especially  cold  and  moist  dressings,  too  early 
use  of  the  limb,  &c. 

In  order  to  hasten  the  consolidation  when  it  is  simply  delayed,  we 
resort  to  all  of  those  expedients  which  are  calculated  to  invigorate 
the  general  system;  and  for  this  purpose  the  employment  of  a  nutri- 
tious diet  and  the  use  of  mineral  or  vegetable  tonics  may  not  be  pro- 
perly omitted  ;  but  in  our  experience  nothing  has  proved  so  efficient 
as  encouraging  the  patient  to  leave  his  bed  and  get  out  into  the  open 
air ;  for  which  purpose,  if  the  fracture  is  in  the  lower  extremities, 
crutches  will  be  necessary. 

As  local  means,  we  may  enumerate  first  the  removal  of  those  local 
causes  which  seem  to  have  interfered  with  the  consolidation  or  with 
the  union.  If  the  fragments  have  been  officiously  disturbed,  it  may 
be  sufficient  to  impose  upon  the  limb  absolute  rest  for  a  certain  length 
of  time ;  and  the  fragments  may  be  more  closely  pressed  against  each 
other ;  in  other  cases  it  will  be  found  necessary  to  remove  the  band- 
ages, expose  the  limb  freely  to  the  light  and  air  at  least  once  or  twice 
daily,  and  to  rub  it  gently  with  the  dry  hand  or  with  some  moderately 
stimulating  oil,  so  as  to  induce  a  more  healthy  condition  of  the  soft 
parts,  and  encourage  the  natural  circulation. 

Moving  the  fragments  freely  upon  each  other,  sufficient  to  determine 
a  degree  of  excitement  in  the  adjacent  tissues,  and  upon  the  opposing 
surfaces  of  the  bones,  and  then  confining  them  during  one  or  two 
weeks  in  firm  and  well-fitting  splints,  will  sometimes  succeed  when 
other  means  have  failed. 

Indeed,  I  may  say  that  by  one  or  another  of  the  simple  methods 
now  enumerated  I  have  never  failed  sooner  or  later  to  effect  consolida- 
tion, in  recent  fractures ;  and  it  has  only  been  in  fractures  of  at  least 
four,  six,  or  eight  months'  standing  that  I  have  been  compelled  to 
resort  to  more  extreme  measures. 

As  a  means  of  combining  immobility  with  compression  and  health- 
ful exercise,  the  "apparatus  immobile,"  in  many  of  its  forms,  is  pecu- 
liarly adapted.  White,  of  Manchester,  employed  a  firm  leather  sheath 
for  the  thigh.  H.  H.  Smith,  of  Philadelphia,  recommends  a  more 
complex  artificial  support,  upon  which  the  limb  may  be  allowed  to 
rest  while  in  the  act  of  progression.^  With  some  surgeons,  the 
object  of  allowing  the  patient  to  walk  in  fractures  of  the  thigh  or 
leg  is  chiefly  to  excite  in  the  tissues  adjacent  to  the  seat  of  fracture 
some  degree  of  inflammatory  action,  but  which,  as  the  result  in  one 
of  White's  patients  has  sufficiently  shown,  may  be  carried  too  far,  and 
even  determine  a  suppuration. 

'  H.  H.  Smith,  A.mer.  Journ.  Med.  ScL,  Jan.  1855. 


DELAYED    AND    NON-UNION    OF    BROKEN    BONES. 


67 


Fio-.  15. 


Dr.  E.  K.  Hudson,  artificial-limb  maker,  of  New  York,  has  applied 
in  similar  cases,  which  have  come  under  my  observation,  an  apparatus 
of  his  own  construction,  made  of  wil- 
low, and  secured  in  place  by  leather 
straps.  In  case  the  purpose  of  the 
apparatus  is  to  encourage  bony  union, 
no  motion  is  allowed  at  the  knee-joint. 

Blisters,  mustard  cataplasms,  the 
tincture  of  iodine,^  caustics,^  &c., 
applied  externally  over  the  seat  of 
fracture,  can  have  no  other  effect  than 
to  increase  moderately  the  congestion 
of  the  tissues,  and  in  so  far  they  may 
aid  in  the  accomplishment  of  the  bony 
union ;  but  in  this  respect  they  are 
inferior  to  the  violent  twistings,  flex- 
ions, and  rubbings  of  the  broken  ends 
of  which  we  have  already  spoken. 

Electricity  was  first  employed  by 
Mr.  Birch,  of  London,  but  Dr.  Mott 
obtained  no  effect  from  it  in  two  cases 
where  he  seems  to  have  given  it  a  fair 
trial.'  Lente,  of  the  New  York  Hos- 
pital, has  furnished  an  account  of  three 
cases  treated  in  that  institution  by 
electricity  in  connection  with  acu- 
puncturation ;  the  mode  of  using 
which  was  to  pass  a  needle  down  to 
the  periosteum  on  each  side  of  the 
bone,  and  to  attach  the  poles  of  the 
battery  to  these  opposite  points. 
Lente  thinks  that  electricity  employ- 
ed in  this  way  is  much  more  efficient 

than  when  the  poles  are  merely  applied  to  the  surface.  He  informs 
us  also  that  other  cases  than  these  now  reported  have  been  treated 
successfully  in  this  hospital  by  means  of  electricity ."^ 

Mercury  will  no  doubt  prove  serviceable  occasionally  by  virtue  of 
its  powers  as  an  anti-syphilitic,  but  its  beneficial  influence  in  other 
cases  is  far  from  having  been  established. 

The  seton  is  said  to  have  been  first  suggested  by  Winslow,  in 
1787 ;  but,  what  is  of  much  more  consequence,  the  credit  of  its  first 
successful  application  and  its  general  introduction  into  practice  is 
due  to  Dr.  Philip  Syng  Physick,  of  Philadelphia,  by  whom  it  was 
employed  in  1802.* 


Hudson's  splint  for  ununited  fractures  of 
femur,  accompanied  with  shortening  of  the 
limb. 


'  Hartshorne,  Eclectic  Rep.,  vol.  iii.  p.  114,  1813. 

2  Willou2;liby,  Am.  Journ.  Med.  Sci.,  Aug.  1834,  p.  444. 

3  Mott,  Med.  and  Surg.  Rep.,  p.  21,  p.  375. 

<  Lente,  New  York  Journ.  Med.,  Nov.  1850,  p.  317. 
«  Pliysick,  Med.  Respository  of  New  York,  vol.  i.  1804. 


68 


DELAYED  AND  NON-UNION  OF  BROKEN  BONES. 


Fig.  16.  Physick  used  for  liis  seton,  generally,  silk  rib- 

bon, or  French  tape ;  and  this  he  introduced  by 
means  of  a  long  seton  needle,  between  the  ends 
of  the  fragments.  He  recommended  that  the 
seton  should  remain  in  place  four  or  five  months, 
and  longer  if  necessary,  and  it  was  his  opinion 
that  the  failures  were  generally  due  to  its  being 
removed  too  early.  At  the  present  day,  however, 
surgeons  who  employ  the  seton  think  it  serves  its 
purpose  better  when  it  remains  in  place  but  a 
few  days,  not  longer,  perhaps,  than  ten  or  fifteen, 
always  taking  care  that  it  is  removed  before  ex- 
cessive suppuration  is  induced.  It  has  been  found 
especially  valuable  in  fractures  of  the  inferior 
maxilla,  clavicle,  and  upper  extremity  generally; 
but  in  the  case  of  the  femur,  it  has  so  frequently 
failed,  that  Dr.  Physick  himself  did  not  recom- 
mend its  use. 

In  case  the  seton  cannot  be  passed  directly 
between  the  opposing  fragments,  as  recommended 
by  Physick,  we  may  adopt  the  practice  suggested 
by  Oppenheim,  and  carry  two  setons,  one  on  each 
side,  close  to  the  bone. 

Somme,  of  Antwerp,  preferred  a  loop  of  wire 
to  the  silk  seton  employed  by  Physick.^  Seerig 
passed  a  ligature  around  the  ligamentous  mass 
connecting  the  two  fragments,  and  then  proceeded 
to  tighten  the  ligature  until  it  fell  off.-  Dr.  Hulse, 
of  the  U.  S.  Navy,  employed  stimulating  injec- 
tions with  success  in  a  case  of  non-union,  accom- 
panied with  an  external  and  fistulous  opening.^ 
In  1848,  Dieft'enbach  recommended  that  ivory 
pegs  be  introduced  into  holes  previously  made  in  the  bone,*  by  means 
of  a  gimlet  or  drill,  and  Mr.  Stanley  has  succeeded  once  by  this 
method.*  Mr.  Hill  introduced  the  ivory  pegs  in  a  case  of  ununited 
fracture  of  the  femur,  pyaemia  supervened,  and  the  patient  died.^ 

Malgaigne,  in  1837,  tried  to  introduce  acupuncture  needles  between 
the  ends  of  an  united  fracture,  but  although  he  thrust  the  needle 
down  to  the  bone  thirty-six  times,  he  was  unable  to  make  it  pass  once 
between  the  ends  of  the  fragments.^  "Wiesel  succeeded  better.  In  a 
case  of  ununited  fracture  of  the  ulna,  of  nine  weeks'  standing,  having 
passed  two  needles  between  the  fragments,  at  the  end  of  six  days,  the 
needles  being  removed,  consolidation  rapidly  ensued.*     This  practice 

'  Amer.  Journ.  Med.  Sci.,  vol.  vii.  p.  497. 

2  Norris,  loc.  cit.,  p.  46. 

3  Hulse,  Amer.  Journ.  Med.  Sci.,  yoI.  xiii.  p.  374. 

♦  Malgaigne,  trans,  by  Packard,  op.  cit.,  p.  258,  note. 

5  Stanley,  New  York  Journ.  Med.,  Nov.  1854,  p.  441,  from  Dublin  Press. 

s  New  York  Med.  Gaz.,  July  4,  1868,  from  the  London  Lancet. 

'  Malgaigne,  op.  cit. 

^  Wiesel,  Amer.  Journ.  Med.  Sci.,  vol.  xxxiv.  p.  254,  July,  1844. 


Physick's  first  case,  after 
28  years.  (From  Am.  Journ. 
Med.  Sci.) 


DELAYED    AND    NON-UNION    OF    BEOKEN    BONES. 


69 


does  not  differ  essentially  from  the  metallic 
loop  of  Somm^,  It  is  only  a  modification  of  the 
seton, 

Brainard,  of  Chicago,  has  attempted  to  show 
that  setons  of  any  kind,  whether  of  wood,  ivory, 
or  metal,  placed  in  contact  with  the  bone,  occa- 
sion absorption,  caries,  and  necrosis,  but  that 
they  never  directly  give  rise  to  bony  callus  ;  and 
that  the  occasional  success  of  the  seton,  which 
success  he  believes  to  have  been  greatly  exag- 
gerated, has  not  resulted  from  any  tendency  to 
favor  the  formation  of  callus,  but  from  the  indu- 
ration and  tenderness  of  the  soft  parts  produced 
by  it ;  circumstances  which,  by  conducing  to  rest, 
indirectly  favor  the  consolidation,' 

In  May,  18-i8,  Miller,  of  Edinburgh,  reported 
five  cases  treated  successfully  by  subcutaneous       Dieffenbach'sdriiisforun- 
puncture.     The  operation   consisted  in  passing     united  fracture, 
the   point  of  a  needle  or  small  tenotomy  bis- 
toury down  upon  the  ends  of  the  bone,  and  freely  irritating  the  sur- 
faces at  several  points.^     George  F.  Sandford,  of  Davenport,  Iowa,  has 
successfully  imitated  this  practice  in  two  cases.^ 

In  1850,  Dr.  William  Detmold,  of  New  York,  performed  the  opera- 
tion of  drilling  or  perforating  the  fragments  in  a  case  of  ununited 
fracture  of  the  tibia,  employing  for  this  purpose  a  large  gimlet.  He 
first  bored  two  holes  between  the  opposing  fragments,  and  then,  intro- 
ducing the  gimlet  one  and  a  half  inch  below  the  fracture,  he  pene- 
trated the  tibia  upwards  and  inwards  until  he  had  traversed,  also,  the 
upper  fragment  to  the  extent  of  an  inch.  In  three  weeks  the  bone 
appeared  firm,  but  from  this  time  the  patient  was  not  seen.^ 

Brainard  employs  for  this  same  purpose  a  strong  metallic  perforator, 
consisting  of  a  handle,  into  which  points  of  different  sizes  may  be  in- 
serted, and  which  have  been  hardened  so  as  to  penetrate  the  hardest 
bone  or  even  ivory  in  every  direction  easily.  The  points  are  "some- 
what awl-shaped ;  but  more  pointed  in  the  middle  rather  than  like  a 
drill,  which  leaves  chips."  His  manner  of  using  this  instrument  is  as 
follows  :  "  In  case  of  an  oblique  fracture,  or  one  with  overlapping,  the 
skin  is  perforated  with  the  instrument  at  such  a  point  as  to  enable  it 
to  be  carried  through  the  ends  of  the  fragments,  to  wound  their  sur- 
faces, and  to  transfix  whatever  tissue  may  be  placed  between  them. 
After  having  transfixed  them  in  one  direction,  it  is  withdrawn  from 
the  bone,  but  not  from  the  skin,  its  direction  changed,  and  another 
perforation  made,  and  this  operation  is  repeated  as  often  as  may  be 
desired."  Dr.  Brainard,  who  has  already  succeeded  by  this  procedure 
in  a  number  of  cases  of  ununited  fracture,  thinks  it  is  better  to  com- 

'  Brainard,  Trans.  Amer.  Med.  Assoc,  vol.  vii.,  1854:  Prize  Essay.     Report  on 
Surgery  to  Illinois  State  Med.  Soc,  May,  1860. 
2  Miller,  New  York  Joum.  Med.,  July,  1848,  p.  134. 
^  Sandford,  Trans.  Amer.  Med.  Assoc.,  vol.  iii.  p.  355,  1850. 
1  New  Y^ork  Med.  Gazette,  Oct.  12,  1850. 


70  DELAYED    AND    XON-UXION    OF    BROKEN    BONES. 

mence  iu  most  cases  with  not  more  than  two  or  three  perforations,  in 
order  that  the  eflect  produced  shall  not  be  too  severe.     It  is  scarcely 

Fiff.  18. 


Brainard's  perforator,  reduced  one-half. 


necessary  to  add  that,  after  the  punctures  have  been  made,  the  limb 
should  be  put  completely  at  rest  in  appropriate  splints,  or  in  apparatus 
of  some  kind. 


F\2:.  19. 


±:3 


The  author's  hone-drill. 

Mr.  Tieman  has  made  for  me  a  bone-drill  which  is  rotated  by  the 
movement  of  a  handle  upon  a  rod  or  shaft  composed  of  twisted  wire, 
and  which  possesses  the  advantage  of  being  worked  with  great  facility 
and  rapidity.  Perforators  of  any  size  or  shape  may  be  fitted  to  the 
shaft  at  pleasure.  In  most  cases  I  have  found  Brainard's  drill  a 
better  instrument  than  my  own. 

Scraping  or  rasping  the  ends  of  the  bones  is  a  practice  which  dates 
from  a  very  early  period.  Mr.  Brodie  scraped  the  ends  of  the  bones, 
and  then  interposed  a  bit  of  lint.^  Mayor,  in  1828,  contrived  to  intro- 
duce an  iron,  previously  heated  in  boiling  water,  through  a  canula, 
and  thus  brought  the  heat  to  bear  directly  upon  the  ends  of  the  frag- 
ments; and  by  repeating  the  application  several  times,  a  cure  was 
effected.^ 

Eesection  of  the  ends  of  the  bones,  first  brought  into  notice  by  White, 
of  Manchester,  in  1760,^  and  opposed  by  Brodie*  as  dangerous,  and 
by  Malgaigne  regarded  as  generally  useless  or  unnecessary,  has  still 
been  practised  a  great  nvimber  of  times,  with  more  or  less  success.  It 
is  especially  applicable  to  superficial  bones,  and  in  cases  where  the 
bones  overlap. 


1  Brodie,  Lond.  Med.  Gaz.,  July,  1834. 

3  Diet,  de  Med.,  vol.  xxiii.  p.  503. 

*  Brodie,  New  York  Journ.,  vol.  viii.  1st  ser.,  p.  133 


^  Norris,  loc.  cit.,  p.  48. 


DELAYED    AND    NOX-UNIOX    OF    BROKEN    BOXES.  71 

Eoux  practised  resection  in  one  instance,  and  then  managed  to  en- 
gage the  point  of  one  of  the  fragments  in  the  medullary  canal  of  the 
otber.^     I  have  succeeded  in  doing  the  same. 

White,  of  Manchester,  Henry  Cline,  of  London,  Hewson,  Barton, 
and  Norris,  of  Philadelphia,  have  applied  caustics  directly  to  the  ends 
of  the  fragments,  after  having  exposed  them  by  a  free  incision.^  Petit 
applied  the  actual  cautery.^ 

Tying  the  fragments  together  by  means  of  metallic  ligatures  after  a 
recent  fracture,  is  as  old  as  the  days  of  Hippocrates;  but  in  1805 
Horeau  adopted  the  same  procedure  in  a  case  of  ununited  fracture."* 
Since  which  date  it  has  been  practised  successfully  by  many  surgeons. 
My  own  experience  confirms  the  value  of  the  method,  especially  when 
the  fragments  overlap. 

E.  S.  Gaillard,  of  Louisville,  Ky.,  proposes  to  secure  the  fragments 
in  place  by  means  of  a  metallic  pin.  The  instrument  which  he  era- 
ploys  is  composed  of  a  steel  shaft  with  a  handle,  a  silver  sheath,  and 
a  brass  nut.  For  a  broken  femur,  the  shaft  is  six  inches  long,  its 
lower  extremity  being  constructed  like  a  gimlet,  while  two  and  a  half 
inches  of  its  upper  extremity  are  cut  for  a  male  screw,  being  intended 
to  carry  the  brass  nut.     The  sheath  is  three  inches  long. 

Through  an  incision  made  over  the  seat  of  fracture,  the  sheath, 
detached  from  the  shaft,  is  carried  down  to  the  bone.  The  shaft  is  then 
passed  through  the  sheath,  and  made  to  penetrate  and  transfix  the  two 
fragments;  as  soon  as  this  is  accomplished,  the  nut  is  turned  down 
firmly  upon  the  top  of  the  sheath,  and  apposition  of  the  fragments  is 
thus  secured.  The  whole  instrument  is  permitted  to  remain  until  bony 
union  is  effected,^ 

Fis.  20. 


Gaillard's  instrument  for  ununited  fractures. 

Finally,  having  thus  brought  rapidly  before  us  all  of  the  various 
modes  of  treatment  which  have  been  suggested  and  practised  for  non- 
union of  broken  bones,  we  are  prepared  to  af&rm  the  following  con- 
clusions, or  summary  of  what  has  been  our  own  practice,  and  of  what 
we  believe  ought  to  be  the  general  course  of  procedure  in  these 
cases : — 

First.  Improve  the  condition  of  the  general  system. 

Second.  Remove  as  far  as  possible  the  local  impediments,  such  as  a 
separation  of  the  fragments,  local  paralysis,  local  scurvy  resulting 
from  long  exclusion  from  light  and  air,  congestions,  &g. 

'  Norris,  loc.  cit.,  p.  49.  2  jbid.  »  Ibid.  *  Ibid. 

5  E.  S.  Gaillard,  New  York  Journ.  Med.,  Nov.  1803. 


72  BENDING  OF  THE  LONG  BONES. 

Third.  Increase  the  action  of  the  tissues  immediately  adjacent  to 
the  fracture,  upon  which  tissues,  rather  than  upon  the  bone,  as  Mal- 
gaigne  thinks,  the  formation  of  callus  depends.  A  theory  which,  as 
applied  to  old  and  ununited  fractures,  we  are  not  prepared  to  deny. 
This  may  be  accomplished  by  frictions,  and  violent  flexions  of  the 
limb  at  the  seat  of  fracture ;  possibly  in  some  measure  by  the  applica- 
tion of  vesicants  or  of  other  stimulants  to  the  skin  itself. 

Fourth.  Employ  again  compression  and  rest  for  a  period  of  from 
two  to  four  or  eight  weeks. 

Fifth.  Kesort  to  the  method  recommended  by  Brainard. 

Sixth.  If  in  the  lower  extremity,  allow  the  patient  to  walk  about 
with  the  fragments  well  supported. 

Seventh.  If  the  fracture  is  not  in  the  femur,  and  as  an  extreme 
measure,  employ  the  seton,  or  resection. 

Where  these  measures  have  failed,  after  a  fair  trial,  we  should 
either  abandon  the  case  as  hopeless,  only  supporting  the  limb  by  such 
apparatus  as  may  be  found  most  serviceable,  or  we  should  recommend 
amputation. 


CHAPTER    VII. 

INCOMPLETE  FRACTURES. 
BENDING,  PARTIAL  FRACTURES,  AND  FISSURES  OF  THE  LONG  BONES. 

§  1.  Bending  of  the  Long  Bones. 

Strictly  speaking,  no  bone  can  be  mucb  bent  without  being  also 
more  or  less  broken,  and  that  whether  it  immediately  and  spontane- 
ously resumes  its  position  or  not ;  for,  if  the  bending  and  straightening 
of  the  bone  be  repeated  a  sufficient  number  of  times,  the  yielding  of 
the  fibres  will  become  apparent,  and  at  length  the  separation  will  be 
complete.  The  first  of  this  series  of  flexions  was  quite  as  much  re- 
sponsible for  this  result  as  the  last,  and,  no  doubt,  performed  its  share 
in  the  production  of  the  complete  fracture. 

There  could  be  no  impropriety,  therefore,  in  speaking  of  a  bending 
of  the  bones  as  a  variety  of  incomplete  fractures,  as  I  have  done  in 
the  first  section  of  my  "  Eeport  on  Deformities  after  Fractures,"  made 
to  the  American  Medical  Association  in  1855.^ 

They  have  been  called,  not  inappropriately,  interperiosteal  fractures, 
since  in  these  cases  the  periosteum  is  not  broken;  M.  Blandin  thinks 
that  the  outer  and  semi-cartilaginous  laminae  of  the  bone  also  do  not 
break,  while  the  deeper  laminee  suffer  an  actual  disruption.^  But  it 
is  quite  as  probable  that  in  a  majority  of  cases  the  true  pathological 

'  Op.  cit.,  pp.  421-422. 

2  Markham's  Obs.  on  the  Surg.  Practice  of  Paris,  Loudon  Med.-Chir.  Rev.,  vol. 
xxxiv.  p.  473,  1841. 


BEXDIXG  OF  THE  LOXG  BONES.  T.S 

condition  is  a  compression  of  the  bony  fibres  upon  one  side,  with  a 
corresponding  expansion  upon  the  opposite  side,  with  only  a  slight 
interstitial  fracture,  too  trivial  to  be  easily  recognized  even  in  the  dis- 
section. Sometimes,  as  I  have  several  times  observed  in  my  experi- 
ments on  the  bones  of  chickens,  when  the  bones  are  small,  and  the 
bending  is  near  the  centre  of  the  shaft,  the  whole  of  the  laminaj  on 
the  side  of  the  retiring  angle  produced  by  the  bending  are  doubled  in,* 
or  indented  toward  the  hollow  of  the  bone,  so  that  the  fibres  on  the 
side  of  the  salient  angle  are  not  even  stretched,  and  much  less  broken. 
In  such  cases,  the  interstitial  disruption,  if  it  exists  at  all,  and  I  think 
it  does,  first  takes  place  in  the  deeper  layers  of  the  retiring  angle. 

I  might,  therefore,  feel  justified  in  continuing  to  call  these  cases 
partial  fractures,  or,  perhaps,  interstitial  fractui'es,  but  I  believe  that 
the  whole  subject  will  be  rendered  more  intelligible  if  I  call  them 
simply  bending  of  the  bones,  as  distinguished  from  those  other  and 
more  palpably  partial  fractures  of  which  I  shall  speak  presently. 

1.  Bending  with  an  immediate  and  spontaneous  restoration  of  the  hone 
to  its  original  form. — The  possibility  of  this  accident,  to  which,  however, 
surgical  writers  have  hitherto  made  no  distinct  allusion,  is  rendered 
certain  by  the  following  experiments  : — 

Experiment  1. — July  16,  1857.  I  bent  the  tibia  of  a  Shanghai 
chicken,  four  weeks  old,  at  about  the  middle  of  the  bone.  It  was  bent 
to  an  angle  of  quite  twenty-five  degrees,  but  it  was  not  felt  or  heard 
to  break.  It  immediately  and  spontaneously  resumed  the  straight 
position. 

July  18,  two  days  after  the  bending,  I  dissected  the  limb,  and  found 
no  trace  of  the  injury,  either  within  or  without  the  bone,  unless  I 
except  a  very  minute  blood-clot  in  the  centre  of  the  shaft. 

Experiment  2. — I  bent  the  leg  of  a  chicken,  four  weeks  old,  at  the 
same  point  and  to  the  same  degree.  It  immediately  resumed  the 
straight  position. 

Dissection  after  two  days.  Nothing  abnormal  except  a  small  blood- 
clot  in  the  centre  of  the  bone,  and  a  slight  disorganization  of  the 
medulla. 

Experiments  3  and  4. — Bent  both  legs  of  a  chicken,  four  weeks  old, 
at  the  same  point,  and  in  the  same  manner.  They  immediately  re- 
sumed their  positions. 

Dissection  after  two  days.  No  lesions  or  morbid  appearances  which 
I  could  detect. 

Experiments  5  and  6. — Bent  both  wings  of  a  chicken  four  weeks 
old.  Bent  the  right  wing  to  an  angle  of  thirty-five  degrees.  I  did 
not  feel  them  break.     Both  resumed  their  positions  spontaneously. 

Dissection  after  two  days.     No  lesions  or  other  morbid  appearances. 

Experiment  7. — July  16,  1857, 1  bent  the  leg  of  a  Shanghai  chicken, 
five  weeks  old,  below  the  knee,  and  about  the  middle  of  the  bone. 
It  was  bent  to  an  angle  of  about  twenty-five  degrees,  but  the  bone  was 
not  felt  or  heard  to  break.  It  immediately  and  spontaneously  resumed 
the  straight  position. 

July  20,  four  days  after  the  bending,  I  dissected  the  leg,  but  could 
not  discover  any  trace  of  the  injury,  except  that  there  was  a  very 
6 


74         BENDING,   PARTIAL    FRACTURES,   AND    FISSURES. 

minute  ossific  deposit  in  the  centre  of  the  bone,  at  the  point  at  which 
I  suppose  it  to  have  been  bent. 

Experiment  8.— July  16,  1857,  I  bent  the  right  leg  of  a  Shanghai 
chicken,  five  weeks  old,  at  the  same  point  as  in  the  first  experiment, 
and  to  the  same  extent.  The  bone  did  not  seem  to  break,  but  it 
immediately  and  spontaneously  resumed  the  straight  position. 

Dissection  after  four  days.  Nothing  appeared  to  indicate  the  seat 
of  the  bending  except  a  small  clot  of  blood  in  the  centre  of  the  shaft. 

Experiment  9. — Bent  the  leg  of  a  chicken,  six  weeks  old,  in  the 
same  manner,  and  to  the  same  degree,  as  in  the  other  examples.  It 
resumed  its  position  spontaneously. 

Dissection  after  ten  days.  No  evidence  of  injury  of  any  kind  ;  the 
bone  being  sound  and  straight. 

These  experiments  were  made  in  connection  with  others  to  which 
more  especial  reference  will  hereafter  be  made.  They  are  selected, 
and  constitute  the  whole  number  of  those  in  which  I  did  not  feel  the 
bone  break  or  crack  under  my  fingers.  In  every  instance  the  bone 
sprung  back  immediately  and  spontaneously  to  its  natural  form.  In 
no  instance  could  I  afterward  discover  any  trace  of  lesion,  or  sign 
indicating  the  point  at  which  the  bone  had  been  bent  before  dissection  ; 
nor  did  dissection  itself  disclose  anything  but  the  most  inconsiderable 
marks  ;  and  that  in  but  three  examples. 

I  infer,  therefore,  not  forgetting  the  caution  with  which  the  conclu- 
sions from  all  such  experiments  ought  to  be  applied  to  similar  acci- 
dents upon  the  human  skeleton,  that  whenever  the  bones  of  healthy 
infants  have  been  slightly  bent  and  not  broken,  they  will,  probably, 
in  most  cases,  unless  prevented  by  causes  foreign  to  the  bones  them- 
selves, spontaneously  and  immediately  resume  their  position;  and 
that  no  sign  will  remain  to  indicate  that  a  bending  has  occurred.  The 
accident  will  not  be  recognized ;  and,  as  a  farther  inference,  this 
bending  does  not  belong  to  that  class  of  cases  of  which  I  shall  next 
speak. 

2.  Bending  without  immediate  and  spontaneous  restoration  of  the  hone 
to  its  original  form. — "  Dethleef,  believing  that  he  had  broken  the  two 
bones  of  the  leg  of  a  dog,  found  the  fibula  bent  without  a  fracture. 
Similar  results  were  obtained  by  Duhamel  upon  a  lamb ;  by  Troja 
upon  a  pigeon ;  and  I  have  myself  twice  succeeded  in  bending  the 
fibula  while  breaking  the  tibia.  The  possibility  of  simple  curvature 
is  then  not  contestable"  (the  writer  means  to  say  that  the  possibility 
•of  a  simple  curvature  remaining  permanently  bent,  is  not  contestable), 
"  but  we  must  observe  that  they  have  never  been  obtained  except 
upon  young  animals,  and  tliat  they  have  been  unable  to  maintain 
themselves  permanently  except  through  the  aid  of  a  fracture  and  dis- 
placement of  a  neighboring  bone ;  and  there  is  a  wide  difference 
between  these  and  those  pretended  curvatures  which  some  believe 
they  have  seen  in  man,  in  which  the  curved  bone  maintains  itself, 
and  resists  perfect  redaction  until  the  fracture  is  complete.'" 

In  this  single  paragraph  Malgaigne  seems  to  have  given  a  fair  sum- 

'  Traits  dcs  Frac,  etc.,  par  L.  F.  Malgaigne,  torn.  i.  p.  48. 


BENDING  OF  THE  LONG  BONES. 


75 


Fi^:.  21. 


mary  of  the  testimony  upon  this  point.  With  the  exception  of  these 
and  a  few  other  similar  examples,  some  of  which  I  think  I  have  ob- 
served myself,  where  one  of  the  bones  of  the  forearm  has  been  broken 
and  the  other  bent,  I  know  of  no  well-attested  cases  of  a  permanent 
bending ;  using  the  terra  bending  in  a  sense  distinguished  from  a  par- 
tial fracture. 

If,  in  numerous  cases  mentioned  by  surgical  writers,  there  has  seemed 
to  be  probable  evidence  that  the  permanent  bending  was  unaccompa- 
nied with  fracture,  there  has  always  been  wanting,  so 
far  as  I  know,  the  positive  evidence  of  dissection.  The 
example  of  partial  fracture  mentioned  by  Fergusson, 
and  represented  by  a  drawing,  is  described  as  having 
also,  "  toward  the  lower  extremity,  a  slight  indentation 
and  curve."'  This  was  the  radius  of  a  child  ;  but  how 
long  the  child  survived  the  accident,  and  what  was  the 
condition  of  the  ulna,  we  are  not  informed.  The  obser- 
vations made  by  Jurine,  of  Geneva,  in  Switzerland,'  by 
Barton^  and  Norris,"*  of  Philadelphia,  all  fail  to  furnish 
any  such  conclusive  evidence  of  the  correctness  of  their 
own  views.  Norris  says  that  "Thierry,  of  Bordeaux, 
Martin,  and  Chevalier,  had  all  met  with  and  published 
cases  of  this  kind  prior  to  the  appearance  of  Jurine's 
paper  (in  1810),  the  former  of  whom  asserts  that  Haller, 
in  experimenting  upon  the  subject,  had  been  able  satis- 
factorily to  produce  the  same  accident  in  young  ani- 
mals." For  myself,  I  cannot  say  how  much  confidence 
we  ought  to  place  in  these  assertions  of  Thierry,  Martin, 
and  Chevalier,  having  never  seen  the  papers  referred^ to;  but  since 
Dr.  Norris  has  neglected  to  inform  us  whether  any  dissections  were 
ever  made,  we  shall  not  be  expected  to  regard  their  testimony  as 
conclusive. 

With  the  qualifications  now  made,  Gibson  was  more  nearly  right 
when  he  said,  "  Dupuytren  and  Dr.  John  Rhea  Barton  have  each  fur- 
nished accounts  of  hent  bones.  There  are  no  such  injuries,  however,  in 
my  opinion  ;  such  cases  being,  in  reality,  par^m?  fractures  from  which 
deformities  result  upon  the  same  principle  that  a  piece  of  tough  wood, 
like  oak  or  hickory,  if  broken  half  through,  may  be  inclined  to  one 
side  and  shortened,  although  still  held  together  by  interlocking  of 
fibres.  Many  specimens  in  my  cabinet,  and  in  the  Wistar  Museum, 
attest  the  accuracy  of  this  assertion."^ 

In  my  own  experiments  upon  the  chicken,  the  bones  uniformly  re- 
sumed their  original  position  as  soon  as  the  restraining  force  was 
removed,  unless  a  fracture  occurred,  and  this  notwithstanding  the 
bones  were  bent  quite  abruptly  and  to  an  angle  of  twenty-five  de- 
grees.    Certainly,  if  the  bones  of  children  may  be  bent  during  life 


Case  mentioned 
by  Fergusson. 


'  Practical  Surgery,  by  William  Fergusson,  4tli  Am.  ed.,  p.  208. 

2  Joum.  de  Corvisart  et  Boyer,  torn.  xx.  p.  278,  etc. 

»  Phila.  Med.  Recorder,  1821. 

«  Phila.  Med.  Joum.,  vol.  xxix.  p.  233,  1842. 

^  Institutes  and  Practice  of  Surgery,  by  Wm.  Gibson,  Phila.  1841,  vol.  i.  p.  254. 


76  BENDING,   PAETIAL    FRACTUEES,    AND    FISSURES. 

and  be  made  to  retain  this  position  without  a  fracture,  then  the  same 
thing  might  be  done  upon  the  bones  of  children  recently  dead,  and, 
by  successful  experiments,  this  long-agitated  question  might  be  easily 
and  forever  put  to  rest. 

It  will  be  understood  that  our  observations  are  confined  to  the  long 
bones.  That  the  flat  bones,  and  especially  the  bones  of  the  cranium, 
in  childhood,  may  be  indented  by  blows,  and  remain  in  this  condi- 
tion, is  undeniable.  Scultetus  says  he  had  seen  "  the  skull  pressed 
down  in  children,  without  a  fracture,  so  that  those  who  touch  or  look 
upon  it  can  perceive  a  small  pit,"'  and  it  has  been  mentioned  by  many 
writers  since,  and  perhaps  before  his  day.  I  have  myself  published 
two  examples  of  it  in  the  second  volume  of  the  Buffalo  Medical 
Journal;^  and  since  the  date  of  that  publication  I  have  met  with 
others. 

§  2.  Partial  Fracture  op  the  Long  Bones. 

1.  Partial  Fracture  with  immediate  and  spontaneous  restoration  of 
the  hone  to  its  original  form. — No  writer  seems  to  have  given  any  spe- 
cial attention  to  the  form  of  fracture  now  under  consideration,  although 
its  existence  appears  to  have  been  occasionally  recognized.  In  the 
case  reported  by  Camper,  in  1765,  of  a  partial  fracture  of  the  tibia, 
the  bone  had  regained  its  natural  form,  but  whether  immediately  after 
the  accident  occurred,  or  at  a  later  period,  I  am  not  able  to  learn.^ 
Jurine,  Gulliver,  and  others,  have  noticed  a  gradual  straightening  of 
the  bone  after  a  partial  fracture,  so  that  its  complete  restoration  has 
been  accomplished  after  several  weeks  or  months ;  but  this,  although 
partly  due  t^  the  same  cause  which  produces  occasionally  an  imme- 
diate restoration,  namely,  its  elasticity,  is  in  part  also  due  to  other 
causes,  and  will  be  more  properly  considered  under  the  next  division 
of  partial  fractures. 

Says  Malgaigne:  "Finally,  at  other  times  the  fracture  takes  place 
without  opening  and  without  curvature;  the  only  sign  which  one  can 
recognize  is  a  yielding  of  the  bone  under  the  pressure  of  the  finger, 
at  the  point  of  fracture;  yet  upon  the  living  subject  we  may  see  the 
same  symptom  pertain  to  complete  and  simple  fractures  without  dis- 
placement."^ 

In  the  following  report  of  one  of  M.  Blandin's  clinics  the  accident 
is  described  a  little  more  distinctly :  "  In  some  cases  of  fracture  of 
the  clavicle  occurring  about  the  middle  of  the  bone  in  young  sub- 
jects, displacement  of  the  fragments  does  not  immediately  take  place, 
thus  giving  rise  to  a  risk  of  an  error  in  diagnosis,  by  which  the  ulti- 
mate probability  of  a  cure  is  diminished.  A  lad  seventeen  years  of 
age  was  recently  admitted  into  the  Hotel  Dieu,  under  the  care  of  M. 
Blandin,  having,  a  few  days  previously,  fallen  upon  one  of  his  com- 
rades while  playing  with  him,  when  'he  instantly  experienced  pain 

1  The  Chirurgeon's  Storehouse,  by  Johannes  Scultetus,  1674,  p.  126. 
'  Op.  cit.,  p.  347,  1846,  Cases  1  and  2. 

»  Essays  and  Obs.  Phys.  and  Lit.  of  Soc.  of  Edinburgh,  vol.  iii.  p.  527. 
*  Op.  cit.,  torn.  i.  p.  50. 


PAETIAL  FEACTURE  OF  THE  LONG  BONES.       77 

and  a  cracking  sensation  about  the  middle  of  the  left  clavicle,  where 
there  soon  formed  a  tumor,  which  increasing,  induced  him  to  enter 
the  hospital.  On  examination,  the  swelling  was  found  to  occupy  the 
middle  of  the  clavicle  ;  it  was  about  as  large  as  half  a  hen's  egg,  ovoid 
in  shape,  well  circumscribed,  colorless,  and  hard,  but  sensible  to  pres- 
sure. There  was  not  any  deformity  of  the  shoulder,  nor  any  abnormal 
modification  of  the  axis  of  the  bone,  to  indicate  the  existence  of  a 
fracture ;  and  although  the  different  movements  of  the  arm  caused 
pain  in  the  shoulder,  yet  they  could  be  made  without  much  difficulty. 

"The  symptoms  in  this  case  would  lead  to  the  belief  that  it  was  a 
case  of  simple  periostitis,  caused  by  external  violence ;  but  M.  Blandin 
at  once  decided  that  there  existed  a  fracture  of  the  bone,  having  seen 
a  similar  case  previously  at  the  hospital  Beaujon,  where  the  tumor 
was  treated  as  traumatic  periostitis,  the  patient  merely  carrying  his 
arm  in  a  sling,  until,  by  a  sudden  movement  of  the  limb,  displace- 
ment of  the  fragments  was  produced,  and  clearly  demonstrated  the 
existence  of  a  fracture.  A  second  case  occurring  soon  afterward,  M. 
Blandin  profited  by  the  experience  gained  from  the  preceding,  and  by 
moving  the  fragments  of  the  broken  clavicle  on  each  other,  obtained 
motion  and  crepitus.  Still  these  indications  were  not  so  clear,  that 
M.  Marjolin  could  diagnosticate  a  fracture ;  he  was  of  opinion  that 
the  case  was  one  of  exostosis,  probably  syphilitic,  and  the  crepitus, 
he  believed,  depended  on  an  erosion  of  the  osseous  surface.  In  con- 
sequence, the  patient  was  left  to  himself,  until  a  movement  of  the  arm 
gave  proof  of  the  fracture  by  the  displacement  of  the  broken  portions 
of  the  bones. 

"  Two  other  cases  occurring  in  young  subjects  have  been  admitted 
since  in  the  Hotel  Dieu,  under  the  care  of  M.  Blandin,  one  of  whom 
was  purposely  left  without  surgical  assistance,  while  Desault's  bandage 
was  applied  to  the  other.  The  former  soon  showed  evidence  of  con- 
secutive displacement ;  the  latter  was  cured  without  any  deformity 
following. 

"  The  surgeon  may  diagnose  a  fracture,  without  displacement  of  the 
middle  portion  of  the  clavicle,  when  a  circumscribed  tumor  forms  in 
that  part  of  young  subjects,  consecutive  on  a  fall  on  the  shoulder,  and 
motion  of  the  fragments,  with  crepitus,  can  be  detected,  there  not 
being  any  syphilitic  taint  in  the  constitution.'" 

The  following  examples,  which  have  come  under  my  own  observa- 
tion, will  illustrate  more  completely  the  usual  history  and  symptoms 
of  these  cases  : — 

A.  B.,  aged  three  years,  fell  from  the  sofa  upon  the  floor,  striking, 
it  is  thought,  on  her  right  shoulder.  Two  days  after  this,  she  fell 
again,  and  then  for  the  first  time,  Mr.  B.  noticed  the  deformity.  She 
was  brought  to  me  three  days  after  the  second  fall.  There  existed 
then  a  round,  smooth  projection  at  the  outer  end  of  the  middle  third 
of  the  clavicle.  It  felt  hard,  like  bone.  The  line  of  the  clavicle  was 
not  changed.     I  advised  a  handkerchief  sling,  simply  to  steady  and 

•  Am.  Journ.  Med.  Sci.,  vol.  xxxi.  p.  473,  from  Journ.  deMed.  et  Chirurg.  Prat., 
July,  1842. 


78  BENDING,    PAETIAL    FRACTUKES,    AND    FISSURES. 

support  the  arm.  Seven  months  after  the  accident,  she  fell  sick  and 
died.  The  projection  continued  at  the  time  of  death,  only  slightly 
diminished. 

H.  S.,  aged  six  years,  was  thrown  from  a  horse,  partially  breaking 
his  left  clavicle,  near  its  middle.  Dr.  Sprague,  of  Buffalo,  was  em- 
ployed. The  projection  in  front  was  for  several  days  very  apparent, 
and  was  examined  by  myself  at  Dr.  Sprague's  request.  The  bone  did 
not  seem  to  be  out  of  line.  Five  years  after  the  accident,  I  examined 
the  lad,  and  could  not  find  any  trace  of  the  original  injury. 

September  25,  1855.  Mrs.  T.  C.  brought  to  me  her  infant  child, 
then  but  two  weeks  old.  Upon  the  left  clavicle,  at  a  point  a  little 
nearer  the  acromion  process  than  the  sternum,  was  an  oblong  swelling, 
three-quarters  of  an  inch  in  length,  smooth  and  hard  like  callus ;  the 
skin  was  not  reddened,  nor  tender.  There  was  no  motion  or  crepitus, 
and  the  line  of  the  axis  of  the  bone  was  perfect.  The  mother,  who 
had  been  put  to  bed  by  a  midwife,  thinks  the  injury  occurred  in  the 
act  of  birth,  although  she  did  not  notice  the  swelling  until  a  week 
after. 

October  20.  Nearly  one  month  later,  I  found  no  change  in  the  con- 
dition of  the  bone ;  the  hard  lump  remained,  but  it  was  still  entirely 
free  from  tenderness.     I  have  not  seen  the  child  since. 

An  infant  boy,  three  years  old,  fell,  August  12, 1857,  from  the  hands 
of  the  nurse.  The  child  cried,  but  the  point  of  injury  was  not  de- 
tected until  the  third  or  fourth  day,  although  the  mother  examined  the 
shoulders  and  neck  carefully  at  the  time.  She  is  quite  certain  that  if 
any  swelling  or  discoloration  had  been  present,  she  would  have  seen  it 
then,  or  on  the  subsequent  days,  while  washing  and  dressing  the  child. 
When  first  seen  it  was  very  distinct,  but  not  so  large  as  at  present. 

August  19.  The  child  was  brought  to  me.  A  little  to  the  sternal 
side  of  the  middle  of  the  right  clavicle  there  was  an  oblong  node-like 
swelling,  of  the  size  of  the  half  of  a  pigeon's  egg,  hard,  smooth,  and 
feeling  like  bone ;  there  was  no  discoloration  or  swelling  of  the  integu- 
ments ;  no  crepitus  or  motion ;  the  line  of  the  clavicle  seemed  nearly 
or  quite  unchanged. 

I  have  not  noticed  this  variety  of  accident  in  any  other  bone  except 
the  clavicle,  yet  it  is  not  improbable  that  it  happens  occasionally,  and 
perhaps  quite  as  often,  in  other  long  bones,  but  that  its  existence  is 
not  elsewhere  so  easily  recognized. 

Of  one  hundred  and  five  fractures  of  the  clavicle  recorded  by  me, 
twenty-two  were  partial  fractures ;  and  of  these  six  were  spontaneously 
and  immediately  restored  to  their  natural  axes. 

In  explanation  of  the  fact  that  hospital  surgeons  have  not  observed 
so  large  a  proportion  of  partial  fractures  of  the  clavicle,  it  must  be 
stated  that  nearly  all  these  cases  of  partial  fracture  were  drawn  from 
private  practice.  Accidents  of  this  class  may  be  often  met  with  in 
dispensaries,  but  they  are  seldom  found  in  hospitals. 

Experiment. — In  fourteen  experiments  upon  the  bones  of  chickens, 
a  partial  fracture,  with  immediate  and  spontaneous  restoration,  has 
occurred  but  once.  In  nine  of  these  cases  the  bones  were  only  bent, 
and  in  five  they  were  partially  broken ;  an  immediate  restoration  has 


PARTIAL  FEACTUEE  OF  THE  LONG  BONES.       79 

occurred,  therefore,  in  one  case  out  of  five  of  partial  fracture;  while 
in  my  reported  examples  of  partial  fracture  of  the  clavicle  it  has  been 
noticed  about  once  in  every  three  or  four  cases.  The  following  is  the 
experiment  to  which  I  have  referred  : — 

I  produced  a  partial  fracture  of  the  tibia  in  a  chicken  six  weeks  old. 
The  fracture  was  near  the  middle  of  the  bone.  I  felt  it  break  under 
my  finger ;  but  on  removing  the  pressure,  it  immediately  and  spon- 
taneously resumed  the  straight  position. 

I  dissected  the  limb  on  tlie  tenth  day.  The  line  of  the  axis  of  the 
bone  was  perfect ;  but  on  the  fractured  side  was  a  node-like  enlarge- 
ment, sufiicient  to  be  distinctly  felt  and  seen  before  the  soft  parts  were 
removed. 

Pathology. — In  no  case,  except  in  my  single  experiment  upon  the 
bone  of  a  chicken,  has  the  actual  condition  been  determined  by  dis- 
section, and  if  any  question  has  existed  heretofore  as  to  the  possibility 
of  an  immediate  and  spontaneous  restoration  after  a  partial  fracture, 
this  experiment  ought  to  decide  it  in  the  afl&rmative ;  but  then  the  first 
nine  experiments  already  quoted  have  shown  that  a  mere  bending  with 
immediate  restoration  leaves  no  such  traces  or  signs  as  have  been  de- 
scribed as  following  these  accidents.  We  have,  therefore,  the  negative 
argument  that,  since  a  bending  with  restoration  leaves  no  signs,  these 
examples  reported  by  myself  and  others  as  having  occurred,  and  as 
having  been  followed  by  a  node-like  swelling,  etc.,  must  have  been 
partial  fractures.  Moreover,  in  one  of  the  cases  of  immediate  resto- 
ration reported  by  Blandin,  there  was  a  feeble  crepitus  :  and  in 
another,  the  subsequent  displacement  proved  the  correctness  of  his 
diagnosis. 

We  conclude,  then,  that  these  are  examples  of  partial  fracture,  but 
that  the  number  of  bony  fibres  which  have  given  way  are  too  incon- 
siderable, as  compared  with  those  not  broken,  to  affect  materially  the 
elasticity  of  the  bone. 

Diagnosis. — The  diagnosis  will  depend  somewhat  upon  the  history 
of  the  accident  as  well  as  upon  the  present  symptoms.  In  no  instance, 
where  I  could  ascertain  the  cause,  have  I  known  an  incomplete  frac- 
ture of  this  variety  produced  by  any  other  than  an  indirect  blow;  and 
where  the  clavicle  has  been  the  seat  of  the  fracture  the  counter-blow 
has  been  received  upon  the  end  of  the  shoulder.  The  fact  possesses, 
therefore,  equal  significance  in  its  relation  to  either  of  the  varieties  of 
partial  fracture ;  but  in  the  case  of  a  partial  fracture  with  a  permanent 
curvature,  the  diagnosis  would  be  complete  without  the  history,  while 
in  this  case  it  might  not  be,  and  a  knowledge  of  the  manner  in  which 
the  accident  occurred  would,  therefore,  be  of  great  importance. 

The  signs,  then,  after  a  knowledge  of  the  fact  that  a  blow  has  been 
received  upon  the  shoulder,  are  a  node-like  swelling  upon  the  anterior 
or  upper  face  of  the  clavicle,  generally  in  its  middle  third,  this  swell- 
ing being  hard,  smooth,  oblong ;  the  skin  only  slightly  or  not  at  all 
swollen  or  tender,  and  in  no  way  discolored,  as  it  would  have  been 
had  the  swelling  upon  the  bone  been  the  result  of  a  direct  blow,  and 
the  line  of  the  axis  of  the  bone  unchanged.  I  have  never  detected 
motion  or  crepitus  at  the  point  of  injury,  yet  we  have  seen  that  Blan- 


80  BENDING,    PARTIAL    FRACTURES,    AND    FISSURES, 


din  was  able  to  detect  botb  in  one  instance ;  nor  has  it  ever  occurred 
to  me  to  see  the  swelling  upon  the  bone  until  two  or  three  days  after 
the  injury  was  received.  We  are  not  likely,  therefore,  to  recognize 
this  accident  immediately  after  its  occurrence.  _ 

Treatment. — In  the  case  of  the  clavicle,  neither  bandages,  slings, 
compresses,  nor  lotions  can  be  of  much  service.  Yet  no  harm  can 
arise  from  employing  a  simple  sling  and  roller  to  confine  the  arm ; 
and  it  is  always  proper  to  enjoin  some  degree  of  care  in  using  the  arm 
of  the  injured  side.  The  consolidation  will  be  speedily  accomplished, 
and  after  a  time  the  ensheathing  callus  will  wholly  disappear. 

If  a  similar  accident  should  occur  in  any  other  of  the  long  bones, 
as  retentive  and  precautionary  means,  splints  ought  to  be  applied,  at 
least  for  a  few  days. 

2.  Partial  Fracture  loitliout  immediate  and  S20ontaneous  restoration  of 
the  lone  to  its  natural  form. — The  causes  of  this  accident  are  the  same 
with  those  which  produce  simple  bending,  or  partial  fracture  with  im- 
mediate and  spontaneous  restoration,  from  which  latter  they  differ 
probably  in  the  greater  extent  of  the  bony  lesion.  Perhaps,  also,  they 
differ  sometimes  in  the  peculiar  form  and  degree  of  the  denticulation 
at  the  seat  of  the  fracture ;  in  consequence  of  which  an  antagonism  of 


Fisr.  23. 


Fig.  23. 


Partial  fracture  of  the  clavicle  without  spontaneous  restoration.    From 
nature  ;  taken  three  weeks  after  the  accident. 

the  fibres  takes  place,  preventing  a  restoration  of 
the  bone  to  its  original  form. 

They  constitute  a  large  majority  of  those  ex- 
amples of  partial  fracture  which  come  under  our 
observation  in  the  various  long  bones.  In  one  hun- 
dred and  five  fractures  of  the  clavicle,  it  has  been 
observed  by  me  sixteen  times.  In  two  hundred 
and  nine  fractures  of  the  radius  and  ulna,  it  has 
occurred  twelve  times. 
It  has  not  happened  to  me  to  meet  with  this  fracture  in  any  other 

bone ;  but  examples  have  been  mentioned  as  having  occurred  in  the 

humerus,  ribs,  femur,  tibia,  and  fibula. 


Partial  fracture  with- 
out restoration  of  the 
bone  to  its  natural  form. 


PAETIAL    FEACTURE    OF    THE    LONG    BONES.  81 

Very  few  surgeons  liave  spoken  of  partial  fractures  in  the  clavicle, 
while  Jurine,  Syme,  Listen,  Miller,  Norris,  and  many  others,  have 
declared  that  it  is  much  more  frequent  in  the  bones  of  the  forearm 
than  elsewhere.  This  does  not  agree  with  my  experience,  according 
to  which  it  occurs  oftener  in  the  clavicle  than  in  the  forearm ;  a 
discrepancy  which  I  cannot  very  well  explain,  except  by  supposing 
that,  in  the  case  of  the  clavicle,  the  accident  has  either  been  over- 
looked entirely  or  misapprehended,  Blandin,  who,  we  have  seen,  has 
reported  five  cases  of  partial  fracture  of  the  clavicle  with  immediate 
restoration,  states  distinctly  that  in  two  of  these  cases  distinguished 
surgeons  of  Hopital  Beaujon  and  Hotel  Dieu  failed  to  recognize  it. 

Says  Turner :  "  The  next  I  shall  descend  to  is  that  of  the  clavicle  or 
collar-bone,  which  I  have  found  the  most  frequently  overlooked,  I 
think,  of  any  other,  till  it  has  been  sometimes  too  late  to  remedy, 
especially  among  the  children  of  poor  people;  for,  though  they  find 
these  little  ones  to  wince,  scream,  or  cry,  upon  the  taking  off  or  putting 
on  their  clothes,  yet,  seeing  that  they  suffer  the  handling  of  their 
wrists  and  arms,  though  it  be  with  pain,  they  suspect  only  some  sprain 
or  wrench,  that  will  go  away  of  itself,  without  regarding  anything 
further  or  looking  out  for  help ;  whereas,  this  fracture  discovers 
itself  as  easily  as  most  others.  For  not  only  the  eye,  in  examining 
or  taking  a  view  of  the  part,  may  plainly  perceive  a  bunching  out  or 
protuberance  of  the  bones  when  the  neck  is  bared  for  that  purpose, 
with  a  sinking  down  in  the  middle  or  on  one  side  thereof,  which  will 
be  still  more  obvious  on  comparing  it  with  its  fellow  on  the  other 
side ;  but  when  it  is  more  obscure,  and  the  bone,  as  it  were,  cracked 
only — a  semi-fracture,  as  we  say — yet,  by  pressing  hard  upon  the  part, 
from  one  extremity  to  the  other,  you  will  find  your  patient  crying 
out  when  you  come  upon  the  place ;  and  by  your  fingers,  so  examining, 
sometimes  perceive  a  sinking  farther  down,  with  a  crackling  of  the 
bone  itself,"! 

Erichsen,  who  regards  all  of  these  cases  as  mere  bendings  of  the 
bones,  remarks  that  it  "most  commonly  occurs  in  the  long  bones, 
especially  the  clavicle,  the  radius,  and  the  femur."^  He  says,  more- 
over, "  Fracture  of  the  clavicle  in  infants  not  unfrequently  occurs,  and 
is  apt  to  be  overlooked.  The  child  cries  and  suffers  pain  whenever 
the  arm  is  moved.  On  examination,  an  irregularity,  with  some 
protuberance,  will  be  felt  about  the  centre  of  the  bone,"^  The  reader 
will  not  fail  to  recognize  in  these  symptoms  the  incomplete  fracture 
of  which  we  are  now  speaking,  although  Erichsen  evidently  believes 
them  to  be  examples  of  complete  fracture. 

In  addition  to  this  testimony  as  to  the  frequency  of  these  fractures 
in  the  clavicle,  I  will  only  mention  that  Johnson,  in  his  review  of 
Markham's  Observations  on  the  Surgical  Practice  of  Paris,  says  that 
"  many  surgeons  have  noticed  the  incomplete  fracture  of  the  clavicle, 
as  of  other  bones,  which  takes  place  in  the  young."^ 

'  Art  of  Sargery,  by  Daniel  Turner,  London,  1742,  vol.  ii.  p,  255. 

2  Science  and  Art  of  Surgery,  Phila.  ed.,  1854,  p.  180. 

3  Science  and  Art  of  Surgery,  Phila.  ed.,  1854,  p.  205. 
»      *  Lend.  Med.-Cliir.  Rev.,  vol.  xxxiv.  p,  474,  1841. 


82 


BENDING,    PARTIAL    FRACTURES,    AND    FISSURES, 


Fig.  24.  Pathology. — The  following  experiment  will  assist 

in  the  elucidation  of  this  point  of  our  subject : — 

Experiment. — I  bent  the  leg  of  a  claicken  five 
weeks  old.  It  cracked  under  my  fingers,  and  re- 
mained bent.  Having  waited  a  few  seconds,  and 
finding  that  it  was  not  restored  to  position,  I  pressed 
upon  it  and  made  it  straight.  The  chicken  walked 
off  without  any  limp. 

On  the  fourth  day,  before  dissection,  the  bone 
looked  as  if  it  was  still  bent;  but  on  removing  the 
soft  parts,  the  line  of  the  axis  of  the  bone  was  found 
to  be  straight.  The  areolar  tissue  under  the  skin 
was  infiltrated  with  lymph,  which  was  most  abun- 
dant near  the  fracture,  and  gradually  diminished 
towards  each  extremity  of  the  limb.  This  effusion 
was  confined  almost  entirely  to  the  front  of  the  limb, 
or  to  that  side  which  had  been  broken,  and  consti- 
tuted the  greater  part  of  the  enlargement  which  I 
had  noticed  before  the  dissection  was  commenced, 
and  which  then  felt  like  bone. 

On  the  front  of  the  bone,  also,  underneath  the  pe- 
riosteum, there  was  a  loose,  honeycomb  deposit  of 
ensheathing  callus,  about  one  line  in  thickness,  and 
extending  upward  and  downward  about  half  an  inch. 
This  callus  surrounded  the  bone  in  three-fourths  of 
its  circumference;  but  there  was  no  callus  on  its 
posterior  surface.  It  was  also  deficient  exactly  along 
the  line  of  fracture,  in  front  and  on  the  sides,  in  consequence  of  which 
an  oblique  groove  remained,  indicating  the  seat  of  the  fracture. 

In  three  other  experiments,  the  particulars  of  which  are  detailed  in 
the  earlier  editions  of  this  book,  similar  results  were  obtained. 

So  early  as  the  year  1673,  a  dissection  made  by  Glaser  demon- 
strated incontestably  the  existence  of  partial  fractures  in  the  shaft, 
and  in  the  direction  of  the  diameter  of  long  bones.^  Camper,  in 
1765,  again  described  a  specimen  which  he  had  seen  f  and  Bonn, 
in  1783,  added  a  third  positive  observation.^ 

M.  Gimele  is,  therefore,  in  error  when  he  ascribes  to  Campaignac 
the  credit  of  having  first  proven  by  dissection  their  existence,  in  a 
paper  communicated  to  the  Academy  of  Medicine  at  Paris,  in  1826. 
Campaignac,  however,  seems  to  have  been  the  first  who  described 
very  particularly  the  condition  of  this  fracture.  He  has  recorded  the 
history  and  dissection  of  two  cases,  one  of  which  occurred  in  the 
fibula,  and  one  in  the  tibia.  The  first  of  these  cases  was  a  girl  twelve 
years  old,  who  survived  the  accident  just  eight  weeks.  The  fracture 
had  occured  near  the  middle  of  the  bone,  and  upon  the  interior  and 
internal  side;  in  which  direction,  resting  against  the  tibia,  the  bone 

'  Malgaigne,  op.  cit.,  p.  44,  from  Th.  Boneti  Sepulcliretum,  1700,  torn.  iii.  p.  424. 
'  Essays  and  Obs.  Phys.  and  Lit.  of  Soc.  of  Edinburgh,  1771,  vol.  iii.  p.  537. 
^  Malgaigne,  op.  cit.,  p.  44,  from  Descript.  Tlies.  Ossium  Morb.  Hoviani,  17S3. 


Part'.al  fracture  after 
union  is  consummated. 


PAKTIAL    FEACTURE    OF    THE    LONG    BONES.  83 

was  found  inclined.  "The  bony  fibres  had  been  broken  at  different 
lengths,  almost  exactly  like  what  takes  place  in  the  branch  of  a  tree 
which  has  been  partially  broken ;  and,  as  we  see  sometimes  in  this 
latter  case,  the  bundles  of  splintered  bony  fibres  abutted  upon  them- 
selves, and  did  not  take  their  places  when  we  endeavored  to  restore 
them ;  so  the  abnormal  angle  which  the  fibula  represented  could  not 
be  effaced,  the  ends  of  the  divided  fasciculi  not  restoring  themselves 
to  their  respective  places.  This  disposition  might  be  especially  seen 
toward  the  anterior  part  of  the  internal  face,  where  a  packet  of  fibres, 
coming  from  below,  was  braced  against  the  upper  lip  of  the  division, 
which  it  thus  held  open.  This  opening  at  first  made  me  think  that 
the  fragments  could  not  have  been  well  consolidated;  but  I  assured 
myself  that  it  was,  and  the  fact  was  subsequently  confirmed  by  the 
Academy  of  Medicine;  all  the  points  which  were  in  contact  were 
found  intimately  united.'" 

Diagnosis. — The  diagnosis  is  not  difficult.  The  distortion  indicates 
sufficiently  the  existence  of  a  fracture,  while  the  complete  absence  of 
crepitus  in  nearly  all  cases,  and  of  either  overlapping  or  lateral  dis- 
placement, must,  generally,  especially  where  the  accident  has  occurred 
in  a  child,  sufficiently  indicate  that  the  fracture  is  incomplete.  It  will 
assist  the  diagnosis  also  to  notice  that  these  accidents  are  almost  con- 
fined to  the  middle  third  of  the  long  bones ;  and  they  are  produced 
usually  by  a  bending  of  the  bones,  the  forces  operating  upon  the 
extremities,  and  not  directly  upon  the  point  which  is  broken. 

In  complete  fractures,  also,  preternatural  mobility  is  so  constant  a 
sign  as  to  be  regarded  as  diagnostic,  while  here  there  is  almost  always 
a  great  degree  of  immobility  at  the  seat  of  fracture.  The  angle  made 
by  the  projecting  extremities  is  usually  rather  gentle  and  smooth ; 
at  other  times  it  is  abrupt,  indicating  a  greater  amount  of  fracture,  or 
that  the  outer  fibres  are  broken  more  irregularly.  The  power  of  using 
the  limb  is  generally  sensibly  impaired,  but  not  completely  lost. 

Treatment. — Jurine,  Murat,  Oampaignac,  Gulliver,  Malgaigne,  witb 
some  others,  have  noticed  the  fact  that  it  is  often  difficult,  and  some- 
times quite  impossible,  to  restore  these  bones  to  position ;  a  cir- 
cumstance which  they  have  justly  ascribed  to  that  condition'  of  the 
fragments  described  l3y  Oampaignac.  The  broken  extremities  of  the 
fasciculi  become  braced  against  each  other,  and  effectually  resist  all 
efforts  to  straighten  the  bone ;  unless,  indeed,  so  much  force  is  used  as 
to  render  the  fracture  complete :  a  result  which,  if  it  should  chance  to 
happen,  need  not  occasion  any  alarm,  since,  while  it  enables  us  at  once 
to  restore  the  bone  to  line,  it  does  not  much  increase  the  danger  of 
lateral  displacement  and  overlapping.  That  the  fracture  has  become 
complete  we  may  know  by  a  sudden  sensation  of  cracking,  by  the  in- 
creased mobility,  and  by  the  crepitus  which  is  now  easily  developed. 

But  we  need  not,  on  the  other  hand,  be  over-anxious  to  straighten 
the  bone  completely,  since  experience  has  shown  that  after  the  lapse 
of  a  few  weeks  or  months  the  natural  form  is  usually  restored  spon- 

•  Des  Fractures  Incompletes  et  des  Fractures  Longitudinales  des  Os  des  Membres  ; 
par  J.  A.  J.  Campaignac.     Paris,  1839,  pp.  9-10. 


84         BENDING,   PARTIAL    FRACTURES,   AND    FISSURES. 

taneously.  I  am  not  now  speaking  of  those  cases  in  which  the  resto- 
ration occurs  immediately,  where  it  is  probable  that  the  splintered 
fibres  offer  no  resistance  to  the  restoration  ;  but  only  of  those  in  which 
the  bone  straightens  so  gradually  as  to  induce  a  belief  that  the  broken 
ends  are  the  cause  of  the  resistance.  To  this  variety  of  accident  belong 
cases  one,  five,  six,  seven,  and  eight,  published  in  my  Report  on  De- 
formities after  Fractures;^  in  one  of  which  the  natural  axis  was  resumed 
in  less  than  four  weeks.  In  a  case  mentioned  by  Gulliver,  it  required 
about  the  same  time  to  render  the  bones  of  the  forearm  perfectly 
straight;  and  in  one  case  mentioned  by  Jurine,  at  the  end  of  six 
months  it  was  "  difficult  to  say  which  arm  had  been  broken,  and  at 
the  end  of  one  year  it  was  impossible." 

Jurine  attributes  this  restoration  to  "muscular  action,  or  more 
especially  to  the  reaction  of  the  compressed  bony  plates;"  but  while 
it  is  easy  to  understand  how  the  reaction  of  the  compressed  fibres 
may  accomplish  the  gradual  restoration,  I  am  unable  to  understand  in 
what  manner  muscular  action  contributes  to  this  result,  since  most  of 
the  muscles  attached  to  the  long  bones  operate  so  much  more  ener- 
getically in  the  direction  of  their  axes  than  in  the  direction  of  their 
diameters.  Indeed,  we  have  often  seen  these  bones  bent  after  com- 
plete fractures,  and  before  the  union  was  consummated,  by  muscular 
action  alone. 

I  repeat,  then,  that  the  gradual  restoration  of  these  bones  is  due  to 
the  same  circumstance  which  produces  at  other  times  an  immediate 
restoration,  namely,  the  elasticity  of  the  unbroken  fibres,  but  wliich 
elasticity,  in  this  latter  instance,  is,  for  a  time,  effectually  resisted  by 
the  bracing  of  the  broken  fibres.  At  length,  however,  in  consequence 
of  the  gradual  absorption  of  the  broken  ends,  the  resistance  is  removed, 
and  the  bone  becomes  straight.  If  this  absorption  refuses  to  take 
place,  and  the  fibres  continue  pressed  forcibly  against  each  other,  as 
in  the  case  described  by  Campaignac,  then  the  bone  remains  perma- 
nently bent. 

Having  straightened  the  bone  as  far  as  is  practicable,  it  only  re- 
mains to  secure  the  fragments  in  place  by  suitable  bandages  or  splints. 
If  the  restoration  is  incomplete,  these  means  may  assist  the  efforts  of 
nature  in  accomplishing  a  gradual  restoration. 

It  is  scarcely  necessary  to  say  that  extension  and  counter-extension 
avail  nothing  in  partial  fractures. 

§  3.  Fissures. 

These  constitute  the  second  principal  form  of  incomplete  fractures, 
or  those  in  which  the  fracture  is  accompanied  with  no  appreciable 
bending,  which  occur  almost  exclusively  in  inflexible  bones,  such  as 
the  compact  bones  of  adults,  and  more  often  in  the  direction  of  their 
axes  than  of  their  diameters.  They  are  complete  so  far  as  they  extend, 
but  they  do  not  completely  sever  the  bone  so  as  to  form  two  distinct 
fragments.     They  have  been  most  frequently  observed  in  the  flat 

'  Trans.  Am.  Med.  Assoc,  vol.  viii.,  1855,  pp.  392-5. 


FISSUEES.  85 

bones,  such  as  the  bones  of  the  skull,  and  in  the  upper  bones  of  the 
face;  occasionally  in  the  long  bones,  both  in  their  diaphyses  and  epi- 
physes, and  rarely  in  the  short  bones. 

M.  Gariel  has  reported,  in  the  BuUetins  de  la  Societe  Anat.,  for  1835, 
a  case  of  fissure  of  the  inferior  maxilla,  occurring  in  a  lad  sixteen  or 
eighteen  years  old.  Palletta  found  a  fissure  extending  partly  through 
the  third  dorsal  vertebra,  in  a  man  who  had  fallen  upon  his  back 
eleven  days  before ;  and  M.  Lisfranc  has  mentioned  a  remarkable 
case  of  fissure  and  partial  fracture,  with  bending  of  five  ribs  in  the 
same  person.^  Malgaigne  believes  that  he  has  seen  one  example  of 
this  variety  of  incomplete  fracture  of  the  scapula,  occurring  through 
a  portion  of  the  infra-spinous  region.  I  have  myself  elsewhere  re- 
corded another,  as  having  been  found  in  the  skeleton  of  Niraham,  an 
Oneida  Indian,  who  was  a  great  fighter,  and  who  died  when  about 
forty-five  years  old,  in  consequence  of  severe  injuries  received  in  a 
street  brawl ;  but  his  death  did  not  occur  until  four  or  five  months 
after  the  receipt  of  the  injuries. 

In  addition  to  this  fracture  of  the  right  scapula,  five  of  his  ribs 
were  broken,  and  both  legs,  all  of  which,  except  the  scapula,  had 
united  completely  by  intermediate  and  ensheathing  callus. 

The  scapula  was  broken  nearly  transversely,  the  fracture  com- 
mencing upon  the  posterior  margin  at  a  point  about  three-quarters  of 
an  inch  below  the  spine,  and  extending  across  the  body  of  the  bone 
one  inch  and  three-quarters,  in  a  direction  inclining  a  little  upwards, 
being  irregularly^  denticulate  and  without  comminution.  The  frag- 
ments were  in  exact  apposition,  and,  throughout  most  of  their  extent, 
in  immediate  contact.  They  were,  however,  not  consolidated  at  any 
point,  but  upon  either  side  of  the  fissure  there  was  a  ridge  of  en- 
sheathing callus,  of  from  one  to  three  or  four  lines  in  breadth,  and  of 
half  a  line  or  less  in  thickness  along  the  broken  margin,  from  which 
point  it  subsided  gradually  to  the  level  of  the  sound  bone.  The  same 
was  observed  upon  the  inner  as  well  as  upon  the  outer  surface  of  the 
scapula.  This  callus  had  assumed  the  character  of  complete  bone, 
but  it  was  more  light  and  spongy  than  the  natural  tissue,  and  the 
outer  surface  had  not  yet  become  lamellated.  Its  blood-canals  and 
bone-cells  opened  everywhere  upon  the  surface. 

Directly  over  the  fracture,  and  between  its  opposing  edges,  no  callus 
existed,  but  as  the  bone  had  lain  some  time  in  the  earth  before  it  was 
exhumed,  it  is  probable  that  a  less  completely  organized  intermediate 
callus  had  occupied  this  space,  and  that,  owing  to  the  less  proportion 
of  earthy  matter  which  it  contained,  it  had  become  decomposed  and 
had  been  removed. 

M.  Voillemier  found  the  head  of  the  humerus  penetrated  by  two  or 
three  fissures  ;^  and  M,  Campaignac  has  reported  the  case  of  a  lad  ten 
or  twelve  years  old,  who  was  compelled  to  submit  to  amputation  of 
his  arm  at  the  shoulder-joint,  in  consequence  of  a  severe' injury,  in 
which  the  humerus  was  found  fissured  from  the  insertion  of  the  del- 

'  Des  Fract.  Incomplet.  et  des  Fissures,  par  J.  A.  J.  Campaignac,  1829,  p.  20. 
*  Malgaigne,  op.  cit.,  p.  35. 


86         BENDING,   PARTIAL    FRACTURES,   AND    FISSURES, 

toid  to  near  the  condyles,  extending  through  the  entire  thickness  of 
the  bone,  and  the  edges  of  the  fissure  so  much  separated  toward  its 
lower  extremity  as  to  admit  the  blade  of  a  knife.^  Chaussier  has 
related  a  case  in  which  a  criminal,  who  died  soon  after  having  sub- 
mitted to  the  torture,  was  found  to  have  a  nearly  longitudinal  fissure 
of  the  radius  in  its  upper  fourth,  and  which  penetrated  half-way 
through  the  thickness  of  the  bone.^  Gulliver  saw  a  fissure  in  the 
pelvis°of  an  infant.^  Malgaigne  has  seen  two  specimens  of  this  frac- 
ture in  the  iliac  bones,  both  of  which  belonged,  as  he  thinks,  to  adults ; 
in  one,  the  fissure  was  limited  to  the  internal  table;'  and  in  the  case 
of  the  lad  reported  by  Gariel,  as  having  a  fissure  of  the  inferior 
maxilla,  there  was  also  found  a  fissure  of  the  left  ilium,  but  which 
was  limited  to  the  outer  table.^ 

M.  J.  Cloquet  has  mentioned  a  case  of  fissure  of  the  shaft  of  the 
femur  passing  through  the  condyles  and  extending  upward  to  near 
the  middle  of  the  bone.  The  fissure  was  produced  by  a  bullet,  which 
had  completely  traversed  the  bone  from  behind  forward,  a  little  above 
the  condyles.^  M.  Malgaigne  has  also  represented,  in  one  of  his  plates, 
a  fissure  of  the  femur  extending  along  the  front  of  the  bone,  some- 
what irregularly,  from  a  point  a  little  below  the  trochanter  minor  to 
near  the  condyles/  The  bone  was  presented  to  the  Museum  of  Yal- 
de-Grace,  by  M.  Fleury ;  but  it  is  to  be  regretted  that  we  have  no 
farther  account  of  this  remarkable  specimen.  Certainly,  in  the  com- 
plete absence  of  any  farther  history  of  the  case,  one  might  be  justified 
in  expressing  a  doubt  whether  it  was  not  a  fissure  occasioned  by  the 
contraction  consequent  upon  exposure  and  drying  after  death. 

The  following  account  of  a  fissure  of  the  neck  of  the  femur,  of  the 
same  character  with  those  which  now  occupy  our  attention,  is  copied 
from  the  proceedings  of  the  "  Boston  Soc.  for  Med.  Improvement,"  at 
its  regular  meeting  in  September,  1856  : — 

"  Partial  Fracture  of  the  Neck  of  the  Femur  in  a  man  set.  44  years. 
Specimen  shown  by  Dr.  Jackson. — The  fracture,  which  appears  as  a 
mere  crack  in  the  bone,  commences  anteriorly  just  above,  but  very 
near  to,  the  insertion  of  the  capsular  ligament,  runs  along  this  inser- 
tion for  about  an  inch,  and  then  extends  directly  upward  to  the  mar- 
gin of  the  head  of  the  bone.  From  this  last  point  it  crosses  the  upper 
surface  of  the  neck  almost  in  a  straight  line,  and  at  a  little  distance 
from  the  margin  of  the  head,  but  afterward  approaches  very  closely 
to  this  margin  posteriorly ;  it  then  turns  downward  and  obliquely 
forward,  and  stops  at  a  point  about  half-way  betwe.en  the  small  tro- 
chanter and  the  head  of  the  femur,  and  two-thirds  of  an  inch  or  more 
anteriorly  to  the  line  of  this  trochanter.  The  fracture  then  involves 
about  three-fourths  of  the  neck  of  the  bone ;  the  inner-anterior  portion 
only  being  spared.     There  is  considerable  motion  between  the  neck 

'  Campaignac,  Des  Fract.  Incomplet.,  «&c.,  p.  24. 
"  Med.  Legale,  p.  447  et  seq.  s  Gazette  M^d.,  1835,  p.  472. 

*  Op.  cit.,  p.  34.  5  Bulletins  de  la  Soc.  Anat.,  1835,  p.  24. 

'  These  du  Concours  de  Pathol.    Externe,  1831,  pi.  xii.,  fig.  7.     Also,  DesFrac, 
etc.,  par  Campaignac,  1829,  p.  19. 
'  Op.  cit.  p.  37,  pi.  1,  fig.  1. 


FISSURES.  87 

and  the  shaft,  and  the  fracture  could,  undoubtedly,  be  completed  with- 
out the  application  of  any  extraordinary  force.  Dr.  J.  referred  to 
other  cases  of  partial  fracture;  but  a  fracture  of  this  sort,  as  occurring 
in  this  situation,  and  in  a  fully  adult  subject,  he  believed  had  never 
before  been  described.  There  was,  also,  in  this  case,  a  transverse  frac- 
ture of  the  same  femur  midway,  with  a  split  extending  upward  nearly 
to  the  neck  of  the  bone ;  and  still  further,  a  fracture  of  the  spine.  The 
patient,  a  laboring  man,  fell  through  two  stories  of  a  building  and 
down  upon  a  hard  floor.  On  the  same  day  he  entered  the  Massachu- 
setts General  Hospital,  and  on  the  18th  day  from  the  time  of  the  acci- 
dent he  died.  The  femur  is  perfectly  healthy  in  structure,  and  no 
changes  are  observable  in  the  bone  about  the  fracture.'" 

Whatever  doubts  may  have  been  thrown  upon  the  possibility  of  this 
accident,  as  applied  to  the  neck  of  the  femur,  by  the  ingenious  argu- 
ments of  Robert  Smith,  of  Dublin,^  the  question  is  now  at  least  deter- 
mined by  an  incontestable  fact.  Dr.  Smith  had  rendered  it  quite  pro- 
bable that  both  Oolles  and  Adams  were  mistaken,  and  that  the  cases 
described  by  them  were  examples  of  impacted  fracture,  and  not  of 
partial  fracture  ;  but,  in  arguing  the  improbability  of  its  occurrence, 
from  the  infrequency  of  fractures  of  the  neck  of  the  femur  in  early 
life,  he  overlooked  the  fact  that  there  were  two  forms  of  incomplete 
fractures,  and  that  it  was  only  the  "  green  stick"  fracture  which  be- 
longed mostly  to  childhood ;  "  fissures"  being  found  most  often  in  the 
bones  of  adults.  Indeed,  I  think  the  example  recorded  by  Tournel 
in  the  Archives  de  Medecine,  had  already,  so  early  as  the  year  1887, 
established  the  possibility  of  a  "  fissure"  in  the  neck  of  the  femur ;  al- 
though by  Malgaigne  this  case  has  been  mentioned  as  an  example  of 
that  other  variety  of  partial  fractures  which  is  almost  peculiar  to 
childhood,  and  in  which  the  bones  yield  quite  as  much  by  bending  as 
by  breaking.  But  the  man  was  eighty-five  years  old,  and,  having 
died  three  months  and  a  half  after  the  accident,  a  long  crevice  was 
found,  extending  nearly  through  the  neck  of  the  femur,  partly  within 
and  partly  without  the  capsule. 

1  have  seen,  in  Dr.  Mutter's  valuable  collection  of  bones  at  Phila- 
delphia, a  specimen  of  fissure  of  the  trochanter  major,  which,  it  is 
believed,  occasioned  the  death  of  the  patient  by  hemorrhage. 

Gulliver  says  there  is  an  example  of  a  fissure  in  a  patella  belonging 
to  the  museum  of  the  Edinburgh  College  of  Surgeons ;  the  fissure  tra- 
versing its  articular  face  only.' 

The  first  example  of  a  fissure  of  the  tibia  is  recorded  by  Corn,  Stal- 
part  Vander-Wiel,  in  1687 ;  and  indeed  this  is,  according  to  Cam- 
paignac,  the  first  exact  observation  of  this  species  of  fracture  which 
our  science  possesses,  although  its  existence  had  been  recognized  by 
the  most  ancient  authors.  A  servant  had  been  kicked  by  a  horse,  and 
after  a  time,  pain  continuing  in  the  limb,  his  surgeon,  Dufoix,  suspected 

'  Bost.  Med.  and  Surg.  Joum.,  vol.  Iv.  p.  351.  See,  also,  Amer.  Journ.  Med. 
Sci.  for  1857,  p.  306,  with  engraving  ;  and  Bigelow  on  Hip  Joint,  p.  137. 

2  Treatise  on  Fractures  in  the  Vicinity  of  Joints,  etc.,  by  Robert  Wm.  Smith, 
Dublin,  1854,  p.  44  et  seq. 

3  Malgaigne,  op.  cit.,  page  35. 


88         BENDING,    PARTIAL    FRACTURES,   AND    FISSURES. 

a  fissure  of  tlie  tibia,  and  having  cut  down  to  the  bone,  a  cure  was 
soon  effected.^ 

In  the  Dupujtren  Museum,  at  Paris,  there  are  two  tibiae  with  linear 
fractures ;  one  without  history,  and  the  other  presented  by  MM.  Mar- 
jolin  and  Eullier,  "  and  which  had  been  broken  by  a  ball."^  In  the 
example  related  by  Campaignac,  a  woman,  having  leaped  from  a 
second-story  window,  died  immediately,  and  upon  examination  she 
was  found  to  have  three  fissures  in  the  upper  portion  of  the  left  tibia, 
one  only  of  which  entered  the  articulation.'' 

Many  examples  of  fissure  from  "  perforating"  gunshot  wounds  of 
the  bone  have  been  observed  during  the  late  war  in  this  country; 
but  as  these  examples  belong  peculiarly  to  military  surgery,  they 
will  be  discussed  more  at  length  in  the  chapter  on  gunshot  fractures. 

Duverney  saw  a  priest  who  had  fallen  and  bruised  the  middle  of  his 
left  leg;  the  swelling  and  pain  consequent  upon  which  were  subdued 
after  a  few  days.  The  patient  believed  himself  cured,  and  acted  ac- 
cordingly. Suddenly,  in  the  night,  he 'was  seized  with  an  acute  pain 
in  the  limb  ;  and  on  cutting  down  to  the  bone,  a  bloody  serum  escaped 
from  between  it  and  the  periosteum,  and  the  bone  was  discovered  to 
be  fissured  longitudinally.  Subsequently  the  tibia  was  trephined,  but 
the  fissure  did  not  reach  the  marrow.  He  recovered  completely  in 
less  than  two  months. 

The  same  writer  mentions  another  case,  in  which  a  soldier  received 
the  kick  of  a  horse  in  the  middle  of  his  left  leg,  which  was  followed 
immediately  by  great  pain,  and  subsequently  by  much  inflammation, 
and  even  gangrene  of  the  skin.  The  wound,  however,  cicatrized 
kindly,  but  after  three  months  he  was  seized  suddenly  with  a  severe 
pain  in  the  limb;  and,  after  the  trial  of  many  remedies,  resort  was 
finally  had  to  the  knife,  when  the  tibia  was  seen  to  be  discolored,  and 
cracked  longitudinally.  On  the  following  day  the  bone  was  opened 
over  the  course  of  the  fissure  with  a  chisel  and  mallet,  and  the  patient 
was  at  once  relieved  by  the  escape  of  a  yellowish  and  very  oti'ensive 
matter.  At  the  next  dressing,  the  bone  was  opened  more  freely  by 
several  applications  of  the  trephine,  and  an  abscess  was  exposed  in 
the  centre  of  the  bone.  The  patient  finally  recovered  after  about  lour 
months.*  M.  Campaignac  saw,  also,  at  the  hospital  La  Charite,  the 
tibia  of  a  woman,  aet.  38  years,  upon  which  were  found  four  fissures; 
the  report  of  which  case  is  accompanied  with  a  wood-cut  illustration.* 

Fissures  may  occur  probably  at  all  periods  of  life,  but  they  are  more 
frequently  found  in  the  bones  of  adults.  Campaignac,  however,  men- 
tions a  fissure  of  the  humerus  in  a  child  ten  or  twelve  years  old,  and 
Gulliver  has  seen  a  fissure  in  the  pelvis  of  an  infant. 

Etiology. — They  may  be  occasioned  by  most  of  those  causes  which 
produce  Iractures  in  general,  such  as  direct  or  indirect  shocks;  but 
they  are  occasioned  much  more  often  by  direct  blows,  especially  when 
inflicted  upon  bones  imperfectly  covered  by  soft  parts,  such  as  the 

'  Campaignac,  op.  cit.,  p.  17.  2  Malgaigne,  op.  cit.,  p.  36. 

3  Campaignac,  op.  cit.,  p.  21.  *  Malgaigne,  op.  cit.,  p.  39  et  seq. 

^  Campaignac,  op.  cit.,  pp.  21-22. 


OSSA    N"ASI.  89 

tibia.  Bullets,  having  violently  struck  or  penetrated  the  bone,  have 
frequently  occasioned  fissures. 

Their  course  may  be  parallel  with  the  axis  of  the  bone,  oblique, 
or  transverse  ;  they  are  often  multiple;  some  merely  enter  the  outer 
laminas,  others  open  into  the  cellular  tissue,  and  others  still  divide  both, 
surfaces  of  the  bone  through  and  through;  and,  according  as  they 
penetrate  more  or  less  deeply  the  bone,  their  lips  will  be  found  to  be 
more  or  less  separated.     They  frequently  extend  into  the  joint  surfaces. 

Diagnosis. — The  signs  which  indicate  the  existence  of  a  fissure  must, 
in  a  large  majority  of  cases,  be  insufficient  to  determine  fully  the 
diagnosis  during  the  life  of  the  patient.  It  is  not  probable  that  such 
fissures  could  ever  be  clearly  made  out  by  the  touch  alone,  where  the 
skin  is  not  broken,  since  the  pain,  swelling,  suppuration,  etc.,  are  only 
characteristic  of  inflammation  of  the  bone  or  of  its  coverings,  and 
might  be  equally  present  whether  a  fracture  existed  or  not.  In  those 
rare  cases  only  in  which  the  flesh  is  torn  off,  and  the  surface  of  the 
bone  is  brought  directly  under  the  observation  of  the  eye,  will  the 
diagnosis  become  certain. 

Treatment. — Fortunately,  an  error  in  judgment  in  this  matter  will 
not  materially,  if  at  all,  prejudice  the  interests  of  the  patient;  since, 
whatever  may  be  the  fact  in  other  respects,  if  the  bone,  or  its  perios- 
teum, or  its  medullary  tissue,  is  inflamed,  and  rest,  with  antiphlogis- 
tics,  does  not  accomplish  its  speedy  resolution,  incisions  and  perfora- 
tions become  inevitable,  if  we  would  give  either  safety  or  relief  to  the 
sufferer.  Accordingly,  in  the  inflammation  and  suppuration  conse- 
quent upon  these  fractures,  we  have  seen  that  it  has  been  occasionally 
found  necessary  to  lay  open  the  soft  tissues  freely,  and  even  to  trephine 
the  bone  at  one  or  more  points. 

Fissures  in  Cartilage. — I  have  once  met  with  a  fissure  in  the  thyroid 
cartilage,  which  constitutes,  so  far  as  I  know,  the  only  example  upon 
record  of  a  fissure  in  cartilaore.' 


CHAPTER    VIII. 

FRACTURES  OF  THE  NOSE. 

§  1.  OssA  Nasi. 

Of  twenty-five  cases  of  fracture  of  the  ossa  nasi  recorded  by  me, 
only  fourteen  were  seen  by  a  surgeon  in  time  to  afford  relief.  It 
seemed  to  me  necessary,  therefore,  that  the  student  should  be  in- 
structed how  frequently  the  nature  of  this  accident  is  overlooked 
by  the  friends,  and  even  by  the  surgeon  himself,  to  the  end  that  he 
might  be  thus  admonished  of  the  necessity  of  always  instituting,  in 

'  See  Buffalo  Med.  Joura.,  vol.  xiii.  Article  entitled  Fracture  of  the  Thyroid 
Cartilage. 

7 


90  FRACTURES    OF    THE    NOSE. 

such  cases,  careful  and  thorough  examinations.  In  some  of  the  cases 
recorded  in  my  notes,  where  surgeons  were  called  in  time,  and  a  de- 
formity remains,  it  is  not  improbable  that  the  accident  was  not  recog- 
nized. The  rapidity  with  which  swelling  ensues  after  severe  blows 
upon  the  nose,  concealing  at  once  the  bones,  and  lifting  the  skin  even 
above  its  natural  level,  explains  these  mistakes.  The  nose,  also,  is 
remarkably  sensitive,  and  the  patient  is  often  exceedingly  reluctant 
to  submit  to  a  thorough  examination.  It  ought,  however,  not  to  be 
forgotten  that  the  omission  on  the  part  of  the  surgeon  to  do  his  duty 
will  not  always  be  excused,  even  though  the  patient  himself  has  pro- 
tested against  his  interference,  especially  where  an  organ  so  prominent, 
and  so  important  to  the  harmony  of  the  face,  is  the  subject  of  his 
neglect  or  mal-adjustment;  since  the  most  trivial  deviation  from  its 
original  form  or  position,  even  to  the  extent  of  one  or  two  lines, 
becomes  a  serious  deformity. 

When  the  ossa  nasi  are  struck  with  considerable  force,  from  before 
and  from  above,  a  transverse  fracture  occurs  usually  within  from  three 
to  six  lines  of  their  lower  and  free  margins,  and  the  fragments  are 
simply  displaced  backwards;  or  if  the  blow  is  received  partially  upon 
one  side,  they  are  displaced  more  or  less  laterally.  This  is  what  will 
happen  in  a  great  majority  of  cases,  as  I  have  proven  by  examinations 
of  the  noses  of  those  persons  who  have  been  the  subjects  of  this  acci- 
dent, and  by  repeated  experiments  upon  the  recent  subject. 

These  fragments  are  generally  loose,  and  easily  pressed  back  into 
place  by  the  use  of  a  proper  instrument.  A  silver  female  catheter, 
which  we  have  seen  recommended  by  surgeons,  may  answer  well 
enough  in  a  few  instances,  but  it  will  more  often  fail.  The  diameter 
of  the  meatus  at  the  point  where  the  instrument  must  touch  in  order 
to  make  effective  pressure  upon  the  ossa  nasi,  is  on  the  average  not 
more  than  two  lines;  and  when  the  membrane  which  lines  it  is  injured, 
it  becomes  quickly  swollen,  and  reduces  the  breadth  of  the  channel  to 
a  line  or  less.  Under  these  circumstances,  any  instrument  of  the  size 
of  a  female  catheter  could  only  be  made  to  reach  and  press  against 
the  nasal  process  of  the  superior  maxilla,  which  is  too  firm  and  un- 
yielding to  allow  it  to  pass  without  the  employment  of  unwarrantable 
force.  In  this  way  it  happens  that  the  operator  is  occasionally  sur- 
prised to  find  how  much  resistance  is  opposed  to  his  efforts  to  lift  the 
bones,  and,  after  repeated  unsuccessful  attempts,  the  case  is  not  unfre- 
quently  given  over.  If,  however,  he  had  used  a  smaller  instrument, 
he  would  have  found  almost  no  resistance  whatever.  A  straight  steel 
director,  or  sound,  or  sometimes  even  a  much  smaller  instrument,  if 
possessing  sufficient  firmness,  is  more  suitable  than  the  catheter.  For 
the  same  reason,  also,  one  ought  never  to  wrap  the  end  of  the  instru- 
ment with  a  piece  of  cotton  cloth,  as  some  have,  I  suspect,  without 
much  consideration,  recommended. 

What  I  have  said  of  the  facility  with  which  these  bones  may  be 
replaced,  when  a  proper  instrument  is  employed,  is  true  only  when 
the  treatment  is  adopted  immediately,  or  at  most  within  a  few  days 
after  the  accident. 

Boyer,  Malgaigne,  and  others  have  noticed  the  fact  that  these  frac- 


OSSA    NASI.  91 

tures  are  repaired  with  great  rapidity.  Hippocrates  thought  the  union 
was  generally  complete  in  six  days;  and  in  a  case  which  has  come 
under  my  own  observation,  the  fragments  were  quite  iirraly  united 
on  the  seventh  day. 

Nor  has  Malgaigne,  whose  observations  are  always  very  accurate, 
overlooked  the  fact,  also,  that  their  repair  is  efiiected  without  the  in- 
terposition of  provisional  callus,  but,  as  it  were,  " par  joremih-e  inten- 
tion!'"' My  own  observation  confirms  this  statement.  Among  all  the 
specimens  which  I  have  seen  in  the  various  college  and  private  col- 
lections illustrating  fractures  of  the  ossa  nasi,  and  amounting  in  all  to 
over  forty,  in  no  instance  has  there  been  detected,  after  a  careful  ex- 
amination, the  slightest  trace  of  provisional  callus. 

I  am  not  certain  that  it  will  always  be  found  so  easy  to  retain  these 
loose  fragments  in  place,  as  it  is  to  replace  them.  The  very  swelling 
which  takes  place  so  promptly  under  the  skin  tends  to  depress  the 
fragments,  unsupported  as  they  are  by  any  counter-force  ;  a  tendency 
which,  possibly,  is  in  some  instances  increased  by  attempts  on  the 
part  of  the  patient  to  clear  his  nostrils  by  snufiing  and  hawking,  I 
have,  in  one  instance,  noticed  very  plainly  a  motion  in  the  fragments 
when  such  efibrts  were  made.  How  we  are  to  remedy  this,  I  am  not 
prepared  to  say.  None  of  the  plans  which  I  have  seen  suggested 
possess,  in  my  estimation,  very  much  practical  value.  Few  patients 
will  consent  to  the  introduction  of  pledgets  of  lint,  or  of  stuffed  bags, 
or,  indeed,  of  aaything  else,  sufficiently  far  up  into  the  nostrils  to 
answer  any  useful  purpose.  The  membrane  is  too  sensitive  and  too 
intolerant  of  irritants  to  enable  us  to  have  recourse  generally  to  such 
methods.  Then,  too,  it  would  require,  on  the  part  of  the  surgeon, 
more  than  ordinary  tact  to  accomplish  so  nice  and  delicate  an  adjust- 
ment of  the  supports  from  below  as  these  cases  demand,  where  the 
slightest  excess  of  pressure,  or  the  least  fault  in  the  position  of  the 
compress,  must  defeat  the  purpose  of  :;he  operator. 

Yet,  if  one  were  disposed  lo  make  the  attempt  in  certain  cases 
where  the  comminution  was  very  great,  or  where,  for  any  other  rea- 
son, the  fragments  would  not  remain  in  place,  I  think  there  could  be 
no  better  plan  than  to  push  up  in  succession  a  number  of  small  pledgets 
of  patent  lint,  smeared  with  simple  cerate,  to  each  one  of  which  there 
has  been  attached,  a  separate  string,  so  arranged  as  that  their  relative 
position  may  be  recognized,  and  that  they  may  at  a  suitable  time  be 
removed  in  the  order  of  their  introduction. 

The  employment  of  canulas,  as  recommended  by  Boyer,  B.  Bell, 
and  others,  allows  of  the  nostrils  being  stuffed  without  interfering 
materially  with  the  breathing;  a  provision,  however,  which  is  quite 
unnecessary  with  a  majority  of  persons,  so  long  as  there  exists  no 
impediment  to  the  free  admission  of  air  through  the  fauces. 

With  nicely  adjusted  compresses  made  of  soft  cotton  or  lint,  and 
secured  upon  the  outside  of  the  nose  with  delicate  strips  of  adhesive 
plaster  or  rollers,  we  shall  be  better  able  to  prevent  the  fragments 
from  becoming  displaced  outwards  than  by  moulds  of  wax,  of  lead,  or 
of  gutta  percha,  under  which  it  is  impossible  to  see  from  hour  to  hour 
what  is  transpiring. 


92  FEACTUEES    OF    THE    NOSE. 

The  complicated  apparatus  devised  by  Dubois  and  recommended 
by  Malgaigne,  to  lift  the  bones  and  retain  them  in  place,  seems  to  me 
indeed  very  ingenious,  but  destitute  of  a  single  practical  advantage. 
A  more  considerable  force  than  that  which  I  have  first  supposed 
will  break,  generally,  the  ossa  nasi  transversely  and  a  little  above 
their  middle,  while,  at  the  same  time,  the  nasal  processes  of  the  supe- 
rior maxillary  bones  may  suffer  slightly. 

With  neither  of  these  accidents  is  the  cribriform  plate  of  the  eth- 
moid likely  to  be  broken  or  disturbed.  Indeed,  in  numerous  experi- 
ments made  upon  the  recent  subject,  and  in  which  the  force  of  the 
blow  was  directed  backwards  and  upwards,  breaking  and  .commi- 
nuting the  nasal  bones  above  and  below  their  middle,  with  also  the 
nasal  processes  of  the  superior  maxillary  bones,  and  the  septum  nasi, 
the  cribriform  plate  of  the  ethmoid  was,  without  an  exception,  unin- 
jured. The  exceeding  tenuity  and  flexibility  of  the  septum  nasi  at 
certain  points  prevents  effectually  the  concussion  from  being  commu- 
nicated through  it  to  the  base  of  the  brain.  If,  therefore,  after  these 
accidents,  cerebral  symptoms  are  occasionally  present,  as  I  have 
myself  twice  seen,^  they  must  be  due  rather  to  the  concussive  effects 
of  the  blow  upon  the  very  summit  of  the  nasal  bones,  Avhere  they  rest 
immediately  upon  the  nasal  spine  of  the  os  frontis,  or  to  some  direct 
impression  upon  the  skull  itself. 

The  amount  of  force  requisite  to  break  in  the  nasal  bones,  at  their 
upper  third,  is  very  great;  no  less,  indeed, than  is  requisite  to  fracture 
the  OS  frontis.  If  they  do  finally  yield  at  this  point,  then  no  doubt 
the  base  of  the  skull  must  yield  also.  Nor  do  I  think  patients  could 
often  be  expected  to  recover  from  an  accident  so  severe.  To  this  class 
of  fractures  belongs  the  specimen  contained  in  my  museum,  in  which 
not  only  both  of  the  nasal  bones  are  sent  in — the  nasal  spine  being 
broken  at  its  base — but  also  the  os  frontis  is  depressed ;  the  nasal  pro- 
cesses of  the  upper  maxillary  bones  are  broken  and  greatly  displaced, 
and  the  anterior  half  of  the  cribriform  plate  of  the  ethmoid  is  forced 
up  into  the  base  of  the  brain.  If  it  is  meant  that  in  these  cases  the 
patient  is  in  danger  from  injury  done  to  the  base  of  the  skull  through 
the  fracture  and  depression  of  the  ossa  nasi,  we  can  appreciate  the 
value  of  the  opinion  ;  but  we  do  not  understand  how  this  danger  can 
exist  when  the  nasal  spine  of  the  os  frontis  is  not  broken,  and  the 
upper  ends  of  the  nasal  bones  are  not  displaced  backwards.  But,  ad- 
mitting that  it  were  possible  in  this  way  to  force  up  the  base  of  the 
skull,  it  does  not  seem  to  me  that  we  ought  to  attach  any  value  to  the 
advice  occasionally  given,  to  attempt  to  restore  the  broken  ethmoid 
by  seizing  upon  the  septum  and  pulling  downwards.  A  force  suffi- 
cient to  break  the  base  of  the  skull  never  fails  to  comminute  and 
detach  almost  completely  the  septum  nasi.  We  are  to  proceed  in 
such  a  case  as  we  would  in  a  case  of  broken  skull.  We  must  lay 
open  the  skin  freely,  and  with  appropriate  instruments  seek  to  elevate 
and  remove,  if  necessary,  the  fragments.     Indeed,  after  such  accidents, 

•  Ecport  on  Deformities  after  Fractures,  Cases  16  and  18. 


OSSA    NASI.  93 

we  shall  generalljseeplainly  enough  that  death  is  inevitable,  and  that 
our  services  will  be  of  no  value. 

Occasionally,  I  have  observed,  the  bones  are  neither  broken  at  their 
lower  ends  nor  through  their  central  diameters,  but  only  at  their 
lateral,  serrated,  or  imbricated  margins.  This  is  rather  a  displace- 
ment, or  dislocation,  than  a  fracture.  It  is  more  likely  to  happen,  I 
think,  in  childhood  than  in  middle  or  old  age,  as  in  the  following 
example : — 

Thomas  Kelley,  aged  four  years,  was  kicked  by  a  horse.  Two 
hours  afterwards,  when  he  was  first  seen  by  a  surgeon,  the  nose  and 
face  were  much  swollen,  and  the  fracture  was  overlooked. 

One  year  after  the  accident,  I  found  both  nasal  bones  depressed 
through  nearly  their  whole  length,  and  especially  in  the  lower  halves. 
The  right  nasal  process  was  also  much  depressed,  and  the  right  nostril 
obstructed.     The  lachrymal  canals  upon  this  side  were  closed. 

Sometimes  the  lower  ends  of  the  nasal  bones  are  bent  backwards, 
or  laterally,  constituting  a  partial  fracture. 

A  lad,  aged  ten  years,  was  hit  by  one  of  his  mates  accidentally  with 
his  elbow,  upon  the  left  side  of  his  nose.  I  was  immediately  called, 
and  found  the  lower  end  of  the  left  os  nasi  displaced  laterally  and 
backward,  so  that  it  rested  under  the  lower  end  of  the  right  os  nasi. 
There  did  not  appear  to  be  any  fracture  beyond  that  which  was  in- 
evitable by  the  mere  separation  of  its  serrated  margins  from  the  bone 
adjoining.  The  angle  formed  by  the  bone  at  the  point  where  the 
bending  had  occurred  was  smooth  and  rounded,  and  not  abrupt  as  in 
a  complete  fracture. 

With  a  steel  instrument,  introduced  into  the  left  nostril,  I  attempted 
to  lift  the  bone  to  its  place.  The  membrane  was  very  sensitive,  and 
the  patient  very  restless  under  my  repeated  efforts.  1  pressed  up- 
wards with  considerable  force,  and  succeeded  at  length  in  bringing 
the  bone  nearly  into  position. 

If  there  is  more  complete  displacement,  the  upper  ends  are  not 
usually  forced  backwards,  but  rather  a  very  little  forwards,  from  their 
articulations  with  the  os  frontis,  and  the  bones  then  swing,  as  it  were, 
upon  the  lower  ends  of  the  nasal  spine,  as  upon  a  pivot.  In  this  con- 
dition they  are  very  firmly  locked,  and  it  requires  considerable  force, 
applied  under  their  lower  extremities,  to  restore  them  to  place. 

Such  seemed  to  be  the  position  of  the  bones  in  the  case  of  the  lad 
Kelley,  already  mentioned,  and  also  in  a  German,  whose  nose  was 
flattened  by  a  severe  blow  when  he  was  eleven  years  old,  whom  I  saw, 
thirteen  years  after  the  accident,  in  the  Buffalo  Hospital.  In  this  last 
example  the  bones  were  very  much  displaced  backwards. 

In  children,  also,  the  nasal  bones  may  be  spread  and  flattened,  the 
lateral  margins  not  being  depressed  or  displaced,  but  only  the  mesial 
line  or  arch  forced  back,  so  as  to  press  aside  the  processes  of  the  supe- 
rior maxilla  ;  which  deformity  may  become  permanent. 

A  block  of  wood  fell  upon  a  child  three  weeks  old,  as  she  was  lying 
in  the  cradle.  The  nature  of  the  injury  was  not  understood  by  the 
parents,  and  no  surgeon  was  called.  The  ossa  nasi  are  now,  twelre 
years  after  the  accident,  much  wider  than  is  natural,  and  depressed ; 


94  FRACTUEES    OF    THE    NOSE. 

the  nasal  processes  of  the  superior  maxilla  appearing  to  have  been 
spread  asunder. 

Jacob  Kibbs,  a  German,  aged  seven  years,  fell  from  a  height  of  forty 
feet,  striking  on  his  face.  His  parents  did  not  suspect  the  injury,  and 
no  surgeon  was  called.  Twenty-four  years  after  this,  I  found  the  nose 
almost  flat.  The  nasal  bones  appeared  unusually  wide,  and  were 
sunken  between  the  processes  of  the  upper  maxillary  bones,  which 
latter  might  be  recognized  by  two  parallel  ridges  on  each  side,  slightly 
rising  above  the  level  of  the  ossa  nasi. 

Benjamin  Bell  and  others  have  spoken  of  tedious  ulcers,  polypi, 
necrosis,  fistula  lachrymalis,  abscesses,  impeded  respiration,  and  im- 
pairment of  the  sense  of  smell  and  of  speech,  as  circumstances  apt  to 
result  from  these  injuries,  and  it  is  certain  that  such  consequences  have 
occasionally  followed ;  but  they  must  generally  be  regarded  as  acci- 
dents due  to  the  state  of  the  general  system,  and  as  having  no  connec- 
tion with  the  fracture,  except  as  this  injury  served  to  awaken  certain 
vicious  tendencies. 

A  gentleman  twenty-five  years  old  was  struck  accidentally  upon  the 
right  side  of  his  nose  by  a  board,  and  the  ossa  nasi  were  displaced  to 
the  left.  A  surgeon  made  an  attempt  to  reduce  them,  but  did  not 
succeed,  and  they  have  remained  displaced  ever  since.  The  nose  for 
a  time  was  much  swollen.  A  few  months  after  the  accident,  a  puru- 
lent discharge  commenced  from  the  right  nostril,  and  at  length  an 
abscess  formed  in  the  right  cheek.  Two  years  later,  when  he  came 
first  under  my  notice,  the  nose  still  continued  to  discharge  pus, 
and  occasionally  it  bled  freely.  There  was  also  a  perforation  of  the 
septum,  of  the  size  of  a  three-cent  piece,  which  had  not  ceased  to 
enlarge. 

No  hereditary  maladies  exist  in  the  family,  except  that,  on  his  father's 
side,  it  has  been  generally  observed  that  wounds  do  not  heal  kindly. 
The  same  is  the  fact  with  him.  When  a  child,  he  was  also  very  sub- 
ject to  epistaxis ;  at  sixteen,  a  pulmonary  difficulty  began,  and  he  had 
more  or  less  cough,  with  haemoptysis,  for  two  years.  Since  then,  his 
health  has  been  good.  He  is  a  lawyer  by  pi-ofession,  but  of  late  he 
Las  lived  in  the  country,  upon  a  farm,  and  has  accustomed  himself  to 
much  out-door  exercise. 

As  to  the  prognosis  in  these  fractures,  I  can  only  say  that  either 
owing  to  the  ignorance  and  carelessness  of  the  patients  themselves, 
who  neglect  to  call  a  surgeon  in  time,  or  to  the  difficulty  of  diagnosis, 
or  to  the  greater  difficulty  in  maintaining  an  adjustment  of  the  frag- 
ments, it  has  hitherto  happened  that,  after  a  fracture  of  the  ossa  nasi, 
more  or  less  deformity  has  usually  remained,  I  have  seen  but  few 
which  could  be  said  to  be  perfectly  restored. 

§  2.  Fractures  and  Displacements  of  the  Septum  Narium. 

Fractures  or  displacements  of  the  septum  narium  must  occur  to 
some  extent  in  all  fractures  of  the  ossa  nasi  accompanied  with  depres- 
sion; but  they  are  also  occasionally  met  with  as  the  results  of  a  blow 


FRACTUKES    AND  DISPLACEMENTS    OP    SEPTUM    NARIUM.      95 

upon  the  nose  which  has  been  insufficient  to  break  the  bones,  and  in 
which  only  the  cartilaginous  portion  of  the  nose  has  been  bent  inward 
upon  the  septum. 

Of  these  simple,  uncomplicated  accidents,  I  have  seen  eight;  in 
four  of  which  no  surgeon  was  employed,  or  surgical  treatment  of  any 
kind  adopted,  and  it  is  quite  probable  that  only  in  a  small  proportion 
of  all  the  cases  was  the  nature  of  the  accident  recognized.  Such,  at 
least,  has  been  generally  the  statement  of  the  patients  themselves. 
The  same  causes  will  explain  this  which  have  been  invoked  to  explain 
similar  oversights  in  cases  of  broken  ossa  nasi.  To  which  we  may 
add,  as  an  additional  reason  why  it  may  be  overlooked,  the  frequency 
of  lateral  distortions  or  deviations  in  the  natural  development  of  this 
septum. 

The  cartilaginous  portion  of  the  septum  is  that  which  is  most  fre- 
quently displaced  by  violence,  and  then  it  is  usually  at  the  point  of 
its  articulation  with  the  bony  septum.  Next,  in  point  of  frequency, 
the  perpendicular  nasal  plate  is  broken,  and  especially  where  it  ap- 
proaches the  vomer.  We  omit  in  this  enumeration,  of  course,  those 
cases  where  the  nasal  bones  themselves  are  broken  down,  in  most  or 
all  of  which,  as  we  have  already  said,  the  perpendicular  plate  is  more 
or  less  fractured  and  displaced.  We  cannot  say  how  often  the  vomer 
is  broken,  since  it  is  beyond  our  observation,  except  in  autopsies.  It 
is  probable,  however,  that  the  force  of  the  concussion  rarely  reaches 
it,  the  cartilage  or  the  perpendicular  plate  giving  way  first  and  easily. 

Where  the  deviation  is  only  lateral,  the  results  are  less  serious,  yet 
sufficiently  so,  in  a  few  instances,  to  demand  our  attention.  Lateral 
obliquity  of  the  lower  portion  of  the  nose  follows  generally,  but  not 
uniformly,  a  lateral  displacement  of  the  cartilage,  and  when  it  does 
exist,  it  is  not  always  proportioned  to  the  amount  of  displacement 
existing  in  the  septum,  so  that  the  septum  is  then  made  to  project 
obliquely  across  the  nasal  passage,  causing  often  a  serious  obstruction 
and  permanent  inconvenience.  In  one  instance,  also,  I  have  known  it 
to  occasion  a  chronic  catarrh. 

A  lad,  get.  15,  was  struck  violently  on  the  nose,  which  became  im- 
mediately much  swollen,  but  no  surgeon  was  called.  Eight  years 
after,  I  found  the  septum  displaced  laterally,  and  to  the  left  side,  pro- 
ducing also  a  slight  lateral  inclination  of  the  end  of  the  nose.  He 
was  unable  to  breathe  freely  through  the  left  nostril,  and  from  the 
same  side  a  catarrhal  discharge  had  continued  from  the  time  of  the 
accident. 

The  following  example,  in  which  the  accident  has  been  followed  by 
a  morbid  condition  of  the  cutaneous  glands,  is  of  more  difficult  ex- 
planation : — 

A  young  man,  set.  23,  called  upon  me,  supposing  that  he  had  a 
polypus  nasi.  I  found  that  in  consequence  of  a  fall  upon  the  ice,  seven 
years  before,  the  septum  narium  had  been  displaced  to  the  right  so  as 
to  almost  completely  close  this  nostril.  In  very  cold  weather,  when 
the  vessels  of  the  membrane  are  contracted,  the  passage  is  more  free. 
The  left  nostril  is  proportionably  wide. 

During  the  last  four  or  five  years,  the  right  side  of  his  face  has  been 


96  FRACTURES    OF    THE    NOSE. 

subject  to  profuse  perspiration.  It  is  almost  constant  in  summer,  and 
only  occasional  in  winter.  The  line  of  division  between  the  perspir- 
ing and  non-perspiring  portions  of  the  face  passes  perpendicularly 
from  the  top  of  the  centre  of  the  forehead,  along  the  ridge  of  the  nose, 
and  down  to  the  centre  of  the  chin.  The  phenomenon  is  due,  perhaps, 
to  an  increased  vascularity  in  the  right  side  of  the  face;  possibly  to 
some  peculiarity  in  the  condition  of  the  nervous  trunks,  occasioned  by 
the  nasal  obstruction. 

A  depression  of  the  cartilage  forming  a  portion  of  the  ridge  of  the 
nose  is  necessarily  accompanied  with  a  corresponding  degree  of  late- 
ral displacement,  with  or  without  fracture,  of  its  perpendicular  portion, 
and  produces,  therefore,  not  only  great  deformity,  sometimes  a  com- 
plete flattening  of  the  end  of  the  nose,  but,  also,  in  some  instances, 
complete  obstruction  of  the  nostrils. 

We  conclude,  from  all  that  we  have  seen,  that  fractures  and  dis- 
placements of  the  septum  narium  are  generally  followed  by  perma- 
nent deformity,  and  occasionally  with  still  more  serious  results.  We 
suggest,  therefore,  a  more  careful  examination  in  recent  injuries,  with 
a  view  to  the  ascertainment  of  its  lesions,  and  it  would  be  well,  cer- 
tainly, if  we  could  devise  some  reliable  mode  of  treatment. 

It  is  doubtful  whether  a  partition  so  thin  and  unsupported  can  ever 
be  well  adjusted  and  supported  by  artificial  means.  We  possess,  how- 
ever, some  advantages  in  the  treatment  of  this  accident  which  we  do 
not  in  the  treatment  of  broken  ossa  nasi,  viz :  facility  of  observation 
and  of  approach,  and  if  we  can  do  little  with  plugs  and  supports  in 
the  one  case,  we  may  possiblj''  do  more  in  the  other.  Nothing  seems 
more  rational,  then,  than  to  plug  carefully  and  equally  each  nostril, 
with  pledgets  of  lint,  while  we  cover  the  outside  of  the  nose  com- 
pletely with  a  nicely  moulded  gutta-percha  splint  or  case,  which 
ought  to  be  made  to  press  snugly  upon  the  sides,  and  permitting  these 
to  remain  for  several  weeks,  or  until  the  cure  is  completed.  The 
papier  mache  of  Dzondi,  employed  by  him  in  cases  of  broken  ossa 
nasi,  would  be  equally  applicable  here;  but  the  gutta  percha,  as  be- 
ing more  plastic,  and  hardening  more  quickly,  ought  to  be  preferred. 

Attempts  to  remedy  the  deformities  of  the  nose  at  a  later  period, 
belong  to  the  department  of  anaplastic  surgery,  and  the  modes  of  pro- 
cedure must  be  varied  according  to  the  circumstances  of  the  case. 

The  following  example  will  serve  as  an  illustration  of  what  may 
sometimes  be  accomplished  in  these  cases: — 

A  young  man  fell  from  a  two-story  window,  striking  upon  his  face. 
A  surgeon  was  called,  but  he  did  not  discover  the  nature  of  the  in- 
jury to  the  nose. 

One  year  after  the  accident  he  called  upon  me  for  relief.  The  car- 
tilaginous portion  of  the  septum  was  broken  just  at  the  ends  of  the 
nasal  bones,  and  forced  backwards  about  three  lines,  producing  a 
striking  depression  at  this  point  of  the  ridge  of  the  nose,  while  at  the 
same  time  the  end  of  the  nose  was  thrown  up.  The  deformity  was 
very  unseemly,  and  annoying  both  to  himself  and  to  his  friends,  who 
at  first  could  scarcely  recognize  him. 

I  introduced  a  narrow,  sharp-pointed  bistoury  through  the  skin  of 


FKACTUEES    OP    THE    MALAR    BONES.  97 

the  nose  on  the  right  side,  and  resting  its  edge  upon  the  ridge  at  the 
junction  of  the  cartilage  with  the  ossa  nasi,  I  cut  the  cartilaginous 
septum  directly  backwards  about  three  lines,  and  then  making  a 
gradual  curve  with  my  knife,  I  cut  downwards  about  eight  lines  to- 
wards the  end  of  the  nose.  The  intercepted  portion  of  cartilage 
could  now  be  easily  lifted  with  a  probe,  and  the  line  of  the  ridge  of 
the  nose  completely  restored.  It  was  at  once  apparent,  also,  that  lift- 
ing the  cartilage  would  depress  the  tip  of  the  nose  and  restore  its 
symmetry. 

To  retain  the  cartilage  in  place,  I  constructed  a  gutta-percha  splint 
of  the  length  and  shape  of  the  nose,  but  so  formed  along  its  middle 
as  that  it  would  not  press  upon  the  cartilage  which  I  had  lifted,  rest- 
ing well  upon  the  ossa  nasi,  but  not  touching  the  ridge  from  the  lower 
ends  of  these  bones  to  the  tip  of  the  nose,  at  which  latter  point  it 
again  received  support.  I  now  passed  a  needle,  armed  with  a  stout 
ligature,  through  the  upper  end  of  the  uplifted  cartilage,  transfixing, 
of  course,  the  skin  on  both  sides  of  the  nose,  and  this  I  tied  firmly 
over  the  splint.  This  accomplished  the  important  object  of  pressing 
backwards  and  downwards  the  tip  of  the  nose,  and  thus  tilting  up 
the  upper  part  of  the  ridge  and  septum,  and  of  more  effectually  se- 
curing the  cartilage  in  place  by  lifting  it  directly  with  the  ligature. 
On  the  second  day  the  ligature  was  removed,  but  the  splint  was  con- 
tinued two  weeks,  during  most  of  which  time  a  band  was  kept  drawn 
across  the  lower  end  of  the  splint,  and  tied  behind  the  neck. 

To  prevent  the  cartilage  from  falling  back  when  final  cicatrization 
occurred,  I  pressed  the  sides  of  the  splint  firmly  towards  each  other, 
just  below  the  incision,  so  as  to  force  as  much  as  possible  the  walls  of 
the  nares  into  the  fissure  of  the  septum,  made  by  lifting  it  up.  The 
result  is  a  complete  and  perfect  restoration  of  the  nose  to  its  original 
form. 

Dr.  James  Bolton,  of  Eichmond,  Ya.,  has  devised  a  very  ingenious 
mode  of  rectifying  an  old  displacement  of  the  septum  nasi.  He 
makes  a  stellate  incision  of  the  septum  in  such  a  manner  as  to  form 
of  it  about  eight  triangles  with  their  apices  converging  to  a  common 
centre.  He  then  seizes  each  triangle  separately  with  a  pair  of  forceps, 
and  breaks  it  at  its  base  without  detaching  it.  Having  thus  commi- 
nuted the  septum,  he  is  able  to  restore  it  to  position  and  retain  it 
until  consolidation  is  effected.' 


CHAPTER  IX. 

FEACTURES  OF  THE  MALAR  BONE. 

I  HAVE  been  unable  to  find  any  records  of  a  simple  fracture  of  the 
malar  bone,  that  is  to  say,  of  a  fracture  unconnected  with  a  fracture 
of  other  bones  of  the  face.    It  is  probable,  however,  that  it  sometimes 

'  Bolton,  Richmond  Med.  Journ.,  April,  1868,  p.  341. 


98  FRACTURES  OF  THE  MALAR  BONES. 

occurs,  but  that,  not  being  accompanied  witli  much  displacement,  it  is 
overlooked.  I  have  myself  seen  a  fracture  of  the  upper  margin,  or 
of  that  portion  which  constitutes  a  part  of  the  orbital  border,  in  two 
or  three  instances,  while  I  was  unable  to  detect  any  other  fracture 
among  the  bones  of  the  face ;  but  it  is  by  no  means  certain  that  other 
fractures  did  not  exist,  perhaps  in  some  of  the  bones  which  form  the 
socket,  or  in  the  superior  maxilla,  as  mere  fissures,  or  as  fractures  with 
only  slight  displacement.  The  prominence  of  the  malar  bone,  and 
especially  the  sharpness  of  its  orbital  margin,  would  enable  the  sur- 
geon to  detect  easily  the  smallest  displacement,  or  even  a  fissure, 
while  a  much  more  extensive  displacement  elsewhere  would  escape 
detection. 

The  two  upper  maxillary  bones  form,  as  they  are  placed  opposite 
to  each  other,  an  irregular  arch,  one  end  of  which  rests  upon  its  fel- 
low, at  the  intermaxillary  suture,  and  the  other  end  rests  upon  the 
nasal  and  frontal  bones ;  while  over  the  centre  of  the  arch  is  situated 
the  malar  bone.  The  force  of  a  side  blow  upon  the  malar  bone  will 
expend  itself,  therefore,  chiefly  upon  the  base  of  the  maxillary  apo- 
physis, as  being  in  the  line  of  the  direction  of  the  force.  The  force 
continuing  to  act,  after  the  apophysis  is  broken,  the  portion  of  the 
superior  maxilla  above  the  floor  of  the  nares  will  fall  inward  toward 
the  septum,  while  the  portion  below  will  tilt  outward  and  open  the 
intermaxillary  suture  along  the  roof  of  the  mouth.  This  suture  will 
also  open  more  widely  in  front  than  behind,  owing  to  the  greater  depth 
of  the  suture  in  front. 

These  observations  I  have  verified  by  several  experiments  made 
with  a  hammer  upon  a  clean  skull. 

One  might  suppose  that  it  would  be  a  very  easy  matter  to  restore 
these  bones  to  place  upon  the  naked  skull,  after  such  an  accident. 
Certainly  it  would  be  very  desirable  to  do  so,  were  this  accident  to 
occur  to  any  patient,  since  the  malar  bone  is  slightly  depressed,  the 
nostril  upon  this  side  is  nearly  closed,  and  the  line  of  the  teeth  is 
disturbed,  and  it  is  possible  also  that  an  opening  might  be  established 
between  the  nose  and  mouth  immediately  back  of  the  incisors.  In 
fact,  however,  I  found  the  restoration  impossible.  It  could  not  be 
accomplished  by  an  instrument  within  the  nose  pressing  outward,  nor 
by  pressing  inward  upon  the  teeth  and  alveoli ;  not,  certainly,  without 
very  great  and  unwarrantable  force.  The  diSicuhy  consisted  simply 
in  the  antagonism  of  the  serrated  margins  of  the  intermaxillary 
suture,  which,  projecting  one  or  two  lines  on  each  side,  could  not  be 
made  to  interlock  again,  but  were  firmly  braced  against  each  other, 

I  shall  not  find  it  necessary  to  report  in  detail  the  results  of  the 
experiments,  but  shall  content  myself  with  stating  that  by  the  second 
blow,  in  the  last  experiment,  the  skull  was  also  found  broken  at  its 
base  through  the  lesser  wings  of  Ingrassias ;  the  force  of  the  blow 
having  been  conveyed,  apparently,  along  the  orbital  plate  of  the  supe- 
rior maxilla  and  os  planum. 

This  is  the  only  example  from  four  experiments  in  which  the  frac- 
ture extended  through  the  dental  arcade,  and  it  was  the  result  of  the 
first  blow.     The  fracture  of  the  base  of  the  skull  by  the  second  blow 


FRACTURES  OF  THE  MALAR  BONES.  99 

indicates  the  possibility  of  producing  a  fatal  lesion  of  the  brain  or  of 
its  bloodvessels  by  a  blow  upon  the  malar  bone. 

General  Summary. — A  fracture  of  the  superior  maxilla  has  occurred 
in  every  instance ;  and  twice  when  the  malar  bone  was  not  broken : 
in  each  of  the  two  last  cases  the  antrum  alone  was  broken,  and  the 
depression  of  the  malar  bone  was  scarcely  noticeable.  In  the  second 
of  these  cases,  the  fracture  extended  also  through  the  dental  arcade. 

In  three  cases  the  nasal  apophysis  has  broken  near  the  base,  and  in 
one  case  at  two  points.  One  of  the  three  fractures  of  the  nasal  apo- 
physis was  accompanied  with  a  diastasis  of  the  superior  maxilla 
through  its  intermaxillary  suture. 

The  malar  bone  has  been  broken  twice  by  the  first  blow,  and  always 
when  the  blow  has  been  repeated.  The  orbital  margin  and  orbital 
plate  have  been  fissured  twice,  the  outer  portion  of  the  orbital  plate 
being  pushed  a  little  into  the  socket.  Once  this  plate  has  been  pushed 
downwards. 

The  zygoma  has  been  broken  three  times,  and  always  transversely, 
a  little  beyond  its  centre,  or  where  the  bone  is  the  most  slender  and 
most  convex. 

The  ethmoid  has  been  broken  three  times,  and  always  longitudinally 
through  the  orbital  plate. 

The  sphenoid  has  been  broken  once,  at  the  base  of  the  skull. 

In  addition  to  these  observations  upon  the  naked  skull,  I  have  seen 
at  least  four  examples,  which  illustrate  the  relative  infrequency  of 
fractures  of  the  malar  bone,  as  compared  with  fractures  of  the  superior 
maxilla  and  of  the  other  bones  of  the  face,  even  when  the  blow  is 
received  directly  upon  the  malar  bone. 

Pat.  Maloney,  aet.  55,  fell  about  twenty  feet  and  struck  upon  his 
face.  Six  weeks  after  the  accident,  while  an  inmate  of  the  Buffalo 
Hospital  of  the  Sisters  of  Charity,  I  found  the  right  malar  bone  de- 
pressed, but  I  could  not  trace  any  line  of  fracture  in  the  malar  bone. 
I  think  the  antrum  of  the  superior  maxilla  was  broken,  and  the  malar 
bone  forced  in  upon  it. 

Thomas  Grotty,  aet.  20,  was  struck  with  a  hoop,  August  15,  1855. 
He  was  seen  immediately  by  a  surgeon  in  Canada,  but  the  fracture 
was  not  recognized.  Five  days  after,  he  called  at  my  office.  I  found 
the  outer  portion  of  the  right  malar  bone  lifted  slightly,  and  the  lower 
and  anterior  angle  depressed  about  three  lines,  as  if  this  portion  had 
been  forced  in  upon  the  antrum. 

The  third  case  will  be  found  reported  under  fractures  of  the  superior 
maxilla,  and  the  fourth  has  been  brought  under  my  notice  in  the 
practice  of  Dr.  Wadsworth,  of  this  city,  the  fracture  having  been  occa- 
sioned by  collision  with  the  head  of  another  man. 

Prognosis. — The  malar  bone  may  be  depressed,  as  we  have  seen,  to 
the  extent  of  two  or  three  lines,  without  being  broken.  This  accident 
will  be  more  properly  considered  under  fractures  of  the  upper  maxilla. 
A  fracture  of  the  malar  bone  implies,  therefore,  generally,  that  great 
force  has  been  applied,  and  that  other  fractures  exist  as  complications. 
This  may  not  be  true,  however,  when  only  the  orbital  margin  of  the 
socket  is  broken.    If  the  orbital  plate  is  broken,  and  a  portion  of  it  is 


100   FEACTURES  OF  THE  UPPER  MAXILLARY  BONES. 

pushed  into  the  socket,  it  may  occasion  a  slight  protrusion  of  the  ball, 
as  in  two  cases  related  by  Dr.  Neill  as  fractures  of  the  upper  maxilla, 
and  as  has  been  noticed  in  the  experiments  already  referred  to.  This 
protrusion  of  the  eyeball  will  probably  continue,  in  some  degree,  as 
long  as  the  bones  remain  displaced.  It  is  quite  probable,  however, 
that  in  some  cases,  after  severe  injuries  of  the  face,  a  moderate  pro- 
trusion of  the  eyeball  is  due  entirely  to  extravasation  of  blood  in  the 
socket;  a  circumstance  which  would  be  likely  to  follow  a  fracture  of 
the  bones  of  the  socket,  and  to  increase  temporarily  the  protrusion  of 
the  eye. 

If  the  body  of  the  bone  is  broken  entirely  through,  and  coma  super- 
venes upon  the  accident,  there  is  some  reason  to  fear  that  the  skull  is 
fractured  at  its  base,  and  the  prognosis  ought  to  be  grave. 

Treatment. — If  there  is  only  a  fissure  of  the  orbital  margin,  it  will 
not  require  attention  ;  but  if  the  fissure  extends  through  the  orbital 
plate,  and  at  the  same  time  the  anterior  and  inferior  margin  of  the 
bone  is  depressed,  in  consequence  of  which  the  orbital  plate  is  tilted 
upward  and  made  to  push  forward  the  eyeball,  the  propriety  of 
surgical  interference  may  be  considered.  If  this  protrusion  is  con- 
siderable, and  evidently  due  to  the  displaced  bone,  an  attempt  should 
be  made  to  lift  the  body  of  the  malar  bone,  and  thus  to  restore  to 
position  its  orbital  plate.  The  method  of  accomplishing  this  I  shall 
describe  particularly  when  speaking  of  fractures  of  the  superior 
maxilla  with  depression  of  the  malar  bones. 


CHAPTER   X. 

FRACTURES  OF  THE  UPPER  MAXILLARY  BONES. 

These  fractures  assume  so  great  a  variety  in  respect  to  form,  situa- 
tion, and  complications,  that  it  would  be  impossible  to  speak  of  them 
systematically,  or  to  establish  anything  but  very  general  rules  as  to 
treatment  and  prognosis. 

They  may  be  broken,  or  loosened  from  each  other  or  from  the  other 
bones  with  which  they  are  articulated,  with  or  without  any  farther 
fracture;  the  nasal  processes  may  be  broken,  and  generally  this  acci- 
dent is  accompanied  with  a  fracture  of  the  nasal  bones  also;  the  malar 
bones  may  be  forced  in,  carrying  with  them  a  portion  of  the  outer  wall 
of  the  antrum ;  the  alveoli  may  be  broken  and  more  or  less  completely 
detached  ;  and  either  of  these  several  fractures  may  be  complicated  with 
fractures  of  the  other  bones  of  the  face,  or  of  the  base  of  the  skull  even. 

Treatment. — When  the  harmonies  of  the  upper  maxillary  bones  are 
only  slightly  disturbed,  nothing  but  a  retentive  treatment  is  necessary. 

A  man  was  thrown  backward  from  a  loaded  cart,  one  wheel  of  the 
cart  passing  over  his  face.  He  was  taken  up  unconscious,  but  when 
I  saw  him  on  the  following  morning,  his  consciousness  had  returned. 


FRACTURES    OF    THE    UPPER    MAXILLARY    BONES.       101 

The  right  malar  bone  was  broken,  and  forced  down  upon  the  antrum 
about  three  lines.  Both  superior  maxilla  were  loosened  from  their 
articulations,  and  could  be  moved  laterally,  the  motion  producing  a 
slight  grating  sound.  The  same  motion  and  grating  occurred  when- 
ever he  attempted  to  swallow.  No  effort  was  made  to  elevate  the 
malar  bones,  nor  did  I  find  any  means  necessary  to  retain  the  maxil- 
lary bones  in  place,  the  amount  of  displacement  being  very  incon- 
siderable, and  never  sufficient  to  be  observed  by  the  eye.  Cool  lotions 
were  applied  constantly  to  the  face,  and  the  patient  was  sustained  by 
a  liquid  diet.  On  the  ninth  day  all  motion  of  the  fragments  had 
ceased,  and  on  the  twenty-seventh  day  the  patient  was  completely 
recovered,  with  only  the  depression  of  the  malar  bone  remaining. 

Sargent,  of  Boston,  reports  a  similar  case,  in  which  a  slight  separa- 
tion of  the  maxillary  bones  united  promptly  and  without  any  reten- 
tive apparatus.^ 

But  in  a  case  in  which  the  superior  maxillary  bones  had  been  more 
completely  torn  from  their  connections,  complicated  with  other  severe 
injuries,  I  found  it  necessary  to  support  the  fragments  by  closing  the 
lower  jaw  upon  the  upper,  and  by  suitable  bandages.  The  patient 
died,  however,  on  the  twelfth  day.^ 

Graefe  recommends,  where  the  bones  are  thus  extensively  separated 
and  displaced,  an  apparatus  made  of  steel,  and  suitably  covered,  which 
is  to  be  applied  against  the  forehead  and  buckled  under  the  occiput. 
From  the  two  sides  descend  a  couple  of  steel  plates,  which,  having 
arrived  at  the  free  border  of  the  upper  lip,  are  reflected  upon  them- 
selves, and  are  made  to  support  upon  their  extremities  long  silver 
gutters,  intended  for  the  reception  of  not  only  the  displaced  teeth  and 
alveoli,  but  also  those  teeth  which  are  firm.^  Yulcanized  rubber  might 
be  substituted  for  the  silver  in  this  apparatus. 

Wiseman  having  been  summoned  to  a  child  with  his  whole  upper 
jaw  forced  in  by  the  kick  of  a  horse,  "beating  the  ethmoides  quite  in 
from  the  os  cribriforme,"  and  forcing  the  palate  bone  against  the  back 
of  the  pharynx,  found  great  difficulty  in  securing  a  permanent  read- 
justment. At  first  he  attempted  to  introduce  his  finger  back  of  the 
bone,  but  failing  in  this,  he  bent  an  instrument  into  the  form  of  a  hook, 
and  passing  it  between  the  bone  and  the  pharynx,  he  easily  replaced 
the  fragments.  But,  on  removing  the  instrument,  they  were  again 
displaced.  Immediately  he  had  constructed  an  instrument  by  which 
the  bones  could  be  not  only  easily  reduced,  but  also  retained  in  place, 
extension  being  made  by  the  hands  of  the  child,  his  mother,  and  others, 
alternately.  In  this  way  the  reunion  was  finally  effected,  and  "the 
face  restored  to  a  good  shape,  better  than  could  have  been  hoped  for."^ 

Harris,  of  New  York,  mentions  a  case  in  which  a  child,  two  years 
old,  having  fallen  from  a  height  of  fifty  feet  upon  the  pavement,  was 
found  to  have  a  diastasis  of  both  the  superior  maxillary  and  palate 

'  Boston  Med.  and  Surg.  Journ.,  vol.  lii.  p.  378. 

2  Report  on  Deformities  after  Fracture.     Trans.  Amer.  Med.  Association,  vol.  viii. 
p.  375,  Case  IV. 
^  Trait6  des  Frac,  etc.,  par  L.  F.  Malgaigne,  p.  373. 
♦  Chirurgical  Treatises,  by  Richard  Wiseman,  173-1,  p.  443. 


102       FRACTURES    OF    THE    UPPER    MAXILLARY    BONES. 

bones;  tbe  separation  being  sufficient  to  admit  tbe  little  finger,  and 
extending  from  between  the  alveoli  which  supported  the  central  in- 
cisors, to  the  soft  palate.  It  is  not  said  whether  any  eflbrts  were  made 
to  reduce  the  bones,  but  six  weeks  after  the  injury  was  received  they 
were  still  open,  and  it  was  proposed  to  close  the  space  by  a  plastic 
operation  as  soon  as  the  condition  of  the  patient  would  warrant  such 
a  procedure.^ 

I  suspect  that  in  this  example,  as  in  my  experiments  referred  to 
under  fracture  of  the  malar  bone,  it  was  found  impossible  to  adjust 
the  bones  and  close  the  intermaxillary  suture,  and  for  the  same 
reasons. 

If,  in  consequence  of  a  blow  received  upon  the  ossa  nasi,  the  nasal 
processes  of  the  superior  maxillae  are  broken  down,  they  may  be  lifted 
and  adjusted  in  the  same  manner  as  the  ossa  nasi. 

I  have  seen  several  examples  of  this  accident,  and  I  have  in  my 
cabinet  a  specimen,  in  which  the  nasal  bones  being  driven  in  by  the 
kick  of  a  horse,  the  nasal  process  upon  the  left  side  is  broken  oft"  just 
above  the  root  of  the  cuspid  tooth,  and  its  upper  end  inclined  inward 
toward  the  nasal  passage  and  backward,  until  it  is  completely  buried. 
In  this  situation  it  has  become  firmly  united  to  the  bony  and  soft 
tissues  into  which  it  was  brought  in  contact. 

The  following  example  will  illustrate  some  of  the  complications 
and  difiiculties  connected  with  a  depression  of  the  malar  bone,  and 
consequent  fracture  of  the  antrum  maxillare. 

M.  P.,  of  Colesville,  aged  about  34  years,  was  thrown  from  a  height, 
striking  upon  his  face,  forcing  the  right  malar  bone  down  upon  the 
antrum  of  the  superior  maxilla.  Dr.  L.  Potter,  of  Yarysburg,  and 
myself  were  called. 

The  deformity  produced  by  the  sinking  of  the  malar  bone  was 
very  striking,  and  both  the  patient  and  myself  were  very  anxious  to 
have  it  remedied,  if  possible.  We  found  some  of  the  teeth  upon  the 
side  of  the  fracture  loose,  and  we  determined  to  extract  them,  and 
press  up  the  bone  with  an  instrument  introduced  through  the  empty 
sockets.  The  first  attempt  to  extract  a  molar  tooth,  however,  brought 
down  several  teeth,  and  the  whole  floor  of  the  antrum.  The  detach- 
ment of  this  fragment  was  also  now  so  complete  that  we  believed  it 
necessary  to  remove  it  entirely,  a  labor  which  was  accomplished  with 
infinite  difficulty,  and  with  no  little  hazard  to  the  patient,  as  dissec- 
tion had  to  be  extended  very  far  back  into  the  throat,  and  in  the  end 
it  was  not  effected  without  bringing  out,  attached  to  the  fragment  of 
maxillary  bone,  a  considerable  portion  of  the  pyramidal  process  of 
the  OS  palati. 

The  time  occupied  in  this  operation  was  at  least  one  hour,  during 
which  we  were  every  moment  in  the  most  painful  apprehensions  lest 
we  should  reach  and  wound  the  internal  carotid,  which  lay  in  such 
close  juxtaposition  to  the  knife  that  we  could  distinctly  feel  its  pulsa- 
tion.    After  its  removal,  the  hemorrhage  was  for  an  hour  or  more 

'  New  York  Journ.  Med.,  vol.  xiii.,  2d  ser.,  p.  214. 


FRACTURES    OF    THE    UPPER    MAXILLARY    BONES.       103 

quite  profuse,  and  could  only  be  restrained  by  sponge  compresses 
pressed  firmly  back  into  the  mouth  and  antrum. 

When  the  hemorrhage  was  sufficiently  controlled,  we  proceeded  to 
examine  the  antrum,  the  floor  of  which  being  removed  entire,  per- 
mitted the  finger  to  enter  freely.  The  restoration  of  the  malar  bone 
was  now  accomplished  without  much  difficulty,  and  with  only  mode- 
rate force. 

Two  years  after  the  accident  the  face  presented,  externally,  no 
traces  of  the  original  injury.  The  malar  bone  seemed  to  be  as  promi- 
nent as  upon  the  opposite  side,  and  there  was  no  perceptible  falling 
in  where  the  teeth  and  alveoli  were  removed.  During  several  months 
after  the  removal  of  the  bone,  the  antrum  continued  to  discharge  pus, 
but  at  length  a  semi-cartilaginous  structure  closed  in  the  cavity 
below,  entirely  reconstructing  its  floor,  and  the  discharge  ceased. 
Since  then  he  has  experienced  no  further  inconvenience. 

I  wish  to  propose  two  or  three  expedients  for  lifting  the  malar  bone 
when  it  has  been  thrust  down,  which  may  in  certain  cases  be  substi- 
tuted for  the  mode  which  has  been  heretofore  generally  adopted. 

In  many  instances  no  difficulty  will  be  experienced  in  resorting  to 
the  usual  method.  The  recent  loss  of  one  or  more  teeth  opposite  the 
floor  of  the  broken  antrum,  or  the  complete  displacement  of  a  tooth 
by  the  accident  itself,  will  give  an  opportunity  for  the  perforation  of 
the  antrum  through  the  open  socket,  and  for  the  introduction  of  a 
suitable  instrument  for  lifting  the  depressed  bone.  Unless,  however, 
the  opening  is  quite  large,  the  instrument  employed  must  be  so  small, 
such  as  a  straight  steel  sound  or  a  female  catheter,  as  to  expose  the 
parts  against  which  its  end  is  made  to  press,  to  some  risk  of  being 
broken  and  penetrated.  It  is  even  possible  in  this  way  to  penetrate 
the  socket  of  the  eye,  and  thus  inflict  serious  injury  upon  the  eye 
itself.  Yet,  with  some  care,  such  accidents  may  be  avoided,  and  it  is 
probable  that  in  the  cases  supposed,  where  the  sockets  of  the  teeth 
opposite  the  base  of  the  antrum  are  open,  this  method  will  continue 
to  have  the  preference. 

But  if  the  teeth  remain  firm  in  their  places,  or  if  they  have  been 
some  time  removed,  and  the  sockets  are  filled  up,  and  we  wish  to  enter 
the  antrum  at  its  base,  we  must  either  drill  through  its  anterior  wall 
above  the  roots  of  the  teeth,  or  we  must  proceed  to  extract  a  tooth. 
The  first  method  gives  an  inconvenient  opening,  and  one  through 
which  it  will  be  necessary  to  use  a  curved  instrument ;  but  yet  it  is  a 
method  far  less  objectionable  than  the  extraction  of  a  tooth  which  is 
firm,  or  which  is  even  tolerably  firm,  in  its  socket,  and  which  may 
require  the  forceps  for  its  removal.  The  objections  to  this  latter  pro- 
cedure were  suggested  by  the  tedious  and  painful  operation  already 
detailed.  The  first  attempt  to  extract  a  tooth  brought  down  the  whole 
floor  of  the  antrum,  with  all  its  corresponding  teeth,  and  the  pyramidal 
process  of  the  palate  bone.  The  tooth  was  already  loose,  and  we 
thought  it  might  easily  be  taken  out,  but  it  had  not  occurred  to  us 
that  it  was  loosened  by  the  comminuted  condition  of  the  walls  of  the 
antrum,  and  of  the  dental  arcade.  The  experiments  made  upon  the 
dead  subject  would  seem  to  show  that  this  fracture  and  comminution 


104   FRACTUKES  OF  THE  UPPER  MAXILLARY  BONES. 

of  the  alveoli  is  not  a  very  frequent  result  of  a  fracture  of  the  antrum 
produced  bj  a  blow  upon  the  malar  bone,  yet  it  may  happen,  and 
whenever  it  does,  the  attempt  to  extract  a  tooth  must  always  expose 
the  patient  to  the  same  hazards.  Certainly  it  is  no  trifling  matter  to 
pull  away  all  of  a  man's  upper  teeth  upon  one  side,  and  to  open  freely 
into  a  broad  cavity  which  might  never  close  again,  and  which,  in 
this  event,  must  always  serve  as  a  place  of  lodgement  for  particles  of 
food,  and  for  foul  secretions,  to  say  nothing  of  the  external  deformity 
which  it  is  likely  to  produce,  and  of  the  severity  and  even  danger  of 
the  operation. 

I  wish,  then,  to  suggest  certain  procedures,  the  value  of  which  I 
have  been  able  to  determine  by  experiment  upon  the  living  subject 
in  two  or  three  cases,  and  which  I  have  carefully  and  frequently 
tested  upon  the  cadaver. 

First  we  ought  to  attempt  to  lift  the  bone  by  putting  the  thumb 
under  its  zygomatic  process  and  body  within  the  mouth.  If  the  bone 
is  thrown  directly  downward,  or  downward  and  backward,  this 
method  can  scarcely  fail ;  and  even  when  it  is  thrown  downward  and 
forward  so  as  to  press  into  the  antrum,  it  is  likely  to  succeed.  If, 
however,  for  any  reason,  the  thumb  cannot  be  brought  to  bear  upon 
its  under  surface,  we  may  make  a  small  incision  upon  the  cheek  over 
the  anterior  margin  of  the  masseter  muscle,  where  its  insertion  into 
the  malar  bone  terminates,  and  pushing  a  strong  blunt  hook  under 
the  bone,  we  may  lift  it  with  ease. 

Where  the  depression  of  the  malar  bone  is  in  the  direction  of  the 
anterior  and  superior  angle  these  means  may  not  be  found  available, 
and  we  may  then  employ  a  screw  elevator,  an  instrument  which  I  find 
already  constructed  in  a  case  of  trephining  instruments  made  for  me 
by  Mr.  Liier,  of  Paris,  and  which  I  have  often  used,  and  constantly 
recommended  to  my  pupils,  in  certain  cases  of  fractures  of  the  skull. 
The  instrument  ought  to  be  made  of  the  best  steel,  and  with  a  broad, 
sharp-cutting  thread.  A  slight  incision  being  made  through  the  skin, 
and  down  to  the  centre  of  the  malar  bone,  the  elevator  is  then  screwed 
firmly  into  its  structure,  and  now  its  elevation  and  adjustment  may  be 
accomplished  with  the  greatest  ease. 

Malgaigne  remarks :  "  In  all  complicated  fractures  of  the  upper 
jaw,  there  is  one  principle  which  surgeons  cannot  too  much  study, 
namely,  that  all  fragments,  however  slightly  adherent  they  may  be, 
ought  to  be  most  carefully  preserved,  and  they  will  be  found  to  unite 
with  wonderful  ease.  This  remark  had  already  been  made  by  Saviard, 
Larrey  insists  strongly  upon  it,  and  we  have  seen  that  M.  Baudens, 
so  great  an  advocate  for  the  removal  of  loose  fragments,  has  declared 
for  these  fractures  a  special  exemption."^ 

Malgaigne  has  here  especial  reference  to  fractures  of  the  dental 
arcade,  and  to  fractures  implicating  the  alveoli  and  extending  more  or 
less  into  the  body  of  the  bone. 

It  would  be  an  error,  however,  to  suppose  that  a  reunion  will  in 

'  Op.  cit.,  vol.  i.  p.  376.     Paris  ed. 


FRACTUEES    OF    THE    UPPER    MAXILLARY    BONES.       105 

these  cases  uniformly  take  place.  Exceptions  have  occurred  in  my 
own  practice,  the  fragments  becoming  loosened  and  completely  de- 
tached after  the  lapse  of  several  weeks.  In  the  case  related  by  Miller, 
the  whole  floor  of  the  antrum  having  been  broken  off,  in  an  unskilful 
attempt  to  extract  the  second  right  upper  molar,  it  was  found  impos- 
sible to  make  it  unite,  and  it  was  subsequently  removed,'  Such 
unfortunate  results  certainly  may  sometimes  be  reasonably  anticipated. 
Yet  they  occur  so  seldom  as  to  justify  the  opinions  and  practice 
advocated  by  Malgaigne. 

In  some  instances,  where  fragments  are  displaced,  carrying  with 
them  several  teeth,  while  others  in  the  same  row  remain  firm,  it  will 
be  sufficient  to  close  the  mouth  and  apply  a  bandage  as  for  fracture  of 
the  inferior  maxilla;  in  others,  the  teeth  and  their  alveoli  ought  to  be 
fastened  with  silk,  or  gold  or  silver  thread  ;  gold,  silver,  gutta-percha, 
or  vulcanite  clasps  may  be  applied  to  the  teeth  and  jaw. 

In  a  case  of  fracture  of  the  right  superior  maxilla,  reported  by 
Baker,  of  Norwich,  N.  Y.,  complicated  with  a  fracture  of  the  inferior 
maxilla,  the  alveoli  were  retained  in  place  ver}^  perfectly  by  a  mould 
of  gutta  percha.^  Neill,  of  Philadelphia,  has  also  reported  three  cases 
of  fracture  of  the  bones  of  the  face,  involving  the  superior  maxilla, 
in  two  of  which  the  eyes  were  made  to  protrude  more  or  less  from 
their  sockets.^  The  loosened  alveoli  were  made  fast  by  wire.  The 
subsequent  deformity  was  inconsiderable,  yet  in  no  instance  was  the 
restoration  complete.^  The  same  method  was  adopted  successfully  by 
a  surgeon  in  Virginia,  in  the  case  of  a  negro  fifty  years  old,  where  most 
of  the  teeth  of  the  left  upper  jaw  were  forced  into  the  mouth,  carrying 
with  them  their  corresponding  alveolar  processes.  The  teeth  remained 
firm  in  their  sockets,  but  the  separation  of  the  bone  was  complete,  the 
fragment  being  held  in  place  only  by  the  mucous  membrane  of  the 
mouth.  On  the  eighth  day  the  surgeon  found  that  the  negro  had 
removed  the  wire,  and  also  the  cork  from  between  his  teeth,  and  the 
maxillary  bandage:  but  the  soft  parts  had  already  united,  and  the 
bones  showed  no  tendency  to  displacement.  His  recovery  was  speedy, 
and  it  was  accomplished  without  any  farther  treatment.^ 

Our  experience  during  the  war  of  the  rebellion  in  this  country  con- 
firms most  of  the  observations  heretofore  made  in  relation  to  these 
fractures.  Owing  to  the  extreme  vascularity  of  bones  composing  the 
upper  jaw,  the  fragments  have  been  found  to  unite,  after  the  most 
severe  gunshot  injuries,  with  surprising  rapidity;  the  amount  of 
necrosis  and  caries  being  usually  inconsiderable,  compared  with 
the  amount  of  comminution.  The  same  anatomical  circumstance, 
namely,  the  vascularity,  has  rendered  these  accidents  peculiarly  liable 
to  troublesome  hemorrhages,  both  primary  and  secondary. 

The  Surgeon-General  reports  that  of  4167  wounds  of  the  face  tran- 

'  News  Let^r,  April,  1854.     Also,  Bost.  Med.  and  Surg.  Joum.,  Tol.  li.  p.  264. 

2  New  York  Joum.  of  Med.,  vol.  i.,  3d  ser.,  p.  362. 

3  See  "  Observations,"  under  Fractures  of  the  Malar  Bone  ;  in  which  the  orbital 
plate  of  the  malar  bone  was  pushed  into  the  sockets. 

*  Phil.  Med.  Exam.,  vol.  x.,  new  ser.,  pp.  455-8. 
5  Amer.  Med.  Gazette,  vol.  viii.,  new  ser.,  p.  106. 

8 


106        FRACTUEES  OF  THE  ZYGOMATIC  ARCH. 

scribed  from  the  reports  from  the  beginning  of  the  war  to  October,  1864, 
there  were  1579  fractures  of  the  facial  bones,  and  of  these  891  re- 
covered, 107  died — the  terminations  are  still  to  be  ascertained  in  581 
cases.  He  farther  remarks  that  secondary  hemorrhage  has  been  the 
principal  source  of  fatality  in  these  cases,  and  that  frequent  recourse 
has  been  had  to  ligation  of  the  carotid,  with  the  result  of  postponing 
for  a  time  the  fatal  event.^ 


CHAPTER   XI. 

FRACTURES  OF  THE  ZYGOMATIC  ARCH. 

The  zygoma,  strictly  speaking,  is  formed  in  a  great  measure  by  the 
body  of  the  malar  bone,  and  it  is  broken  whenever  the  malar  bone  is 
completely  separated  through  any  portion  of  its  body;  but  I  propose 
to  confine  my  remarks  to  that  portion  only  which  is  composed  of  the 
two  processes,  called  respectively  the  zygomatic  processes  of  the  malar 
and  temporal  bone. 

Duverney  relates  a  case  in  which  a  young  child,  having  in  his 
mouth  the  end  of  a  lace-spindle,  fell  forwards  and  thrust  the  spindle 
through  the  mouth  from  within  outwards,  breaking  the  zygoma  in  the 
same  direction,  and  leaving  the  fragments  salient  outwards.^  To  which 
case  of  outward  displacement  Packard,  in  a  note  to  Malgaigne's  work 
on  fractures,  &c.,  has  added  a  second.- 

1  know  of  no  other  examples  in  which  the  fragments  have  been 
thrust  outwards.  A  reference  to  my  experiments  upon  the  naked 
skull  will;  however,  show  that  the  zygoma  may  be  broken  and  dis- 
placed in  the  same  direction,  by  any  force  which  shall  fracture  the 
superior  maxilla,  and  depress  the  anterior  margin  of  the  malar  bone. 
In  my  experiments  this  has  happened  three  times,  and  always  at  the 
same  point,  viz.,  a  little  beyond  the  middle  of  the  zygoma,  near  where 
the  suture  which  joins  the  two  processes  terminates  below.  The 
fractures  were  always  transverse,  and  not  in  the  line  of  the  suture. 
They  were  therefore  fractures  of  that  portion  of  the  zygoma  which 
belongs  to  the  temporal  bone. 

I  suspect,  also,  that  to  this  class  of  cases  belongs  the  example  re- 
lated by  Dupuytren,  in  which  the  patient  having  died  on  the  fifth  day, 
from  the  effects  of  the  cerebral  concussion,  the  autopsy  disclosed  "a 
fracture  through  the  zygomatic  arch  ;  and  that  part  of  the  superior 
maxillary  bone  which  constitutes  the  antrum  was  driven  in."* 

In  another  case  mentioned  by  Dupuytren,  produced  by  a  direct 
blow,  the  fracture  was  compound  and  comminuted,  and  although  the 

'  Circular  No.  6,  Washington,  Nov.  1,  1865,  p.  20. 

2  Bulletin  de  la  Societe  Anatomique,  p.  138,  1810. 

3  Op.  cit.,  p.  289,  vol.  i. 

«  Injuries  and  Diseases  of  Bones,  by  Baron  Dupuytren.  Syd.  ed.,  Loudon,  1847, 
p.  336. 


FRACTUEES  OF  THE  ZYGOMATIC  ARCH.        107 

fragments  were  raised  easily  by  an  elevator,  suppuration  ensued  be- 
neath, and  the  matter  was  discharged  within  the  mouth,' 

Tavignot  reports  a  case  of  fracture  of  this  arch  which  was  not  dis- 
covered until  after  death,  the  fragments  not  being  at  all  displaced.^ 

Dr.  John  Boardman,  one  of  the  surgeons  to  the  Buffalo  Hospital  of 
the  Sisters  of  Charity,  informs  me  that  he  has  met  with  a  fracture  of 
the  zygoma  in  a  man  about  thirty  years  of  age,  occasioned  by  a  blow 
from  a  cricket  ball.  Dr.  Boardman  saw  him  on  the  fourth  day,  and 
ascertained  that  immediately  on  the  receipt  of  the  injury  he  felt 
slightly  stunned,  and  that  he  soon  recovered  from  this,  but  was  unable 
to  open  his  mouth  except  by  pulling  it  open  with  his  hand;  neither 
could  he  close  it  except  in  the  same  manner.  This  immobility  of  the 
jaw  continued  several  days  with  only  very  slight  improvement;  at 
the  end  of  five  weeks,  however,  when  last  seen,  the  mobility  was 
nearly,  but  not  quite,  restored.  The  depression,  a  little  in  front  of 
the  centre  of  the  zygoma,  was  discovered  by  the  patient  himself  im- 
mediately after  the  receipt  of  the  injury,  and  he  says  he  tried  at  once 
to  ascertain  whether  he  could  not  push  the  fragments  back  by  moving 
the  jaw.  He  was  unable  to  make  any  impression  upon  them  by  this 
manoeuvre.  The  depression  still  remains,  but  it  is  not  so  distinct  as 
it  was  when  first  seen. 

Symptoms. — An  irregular  projection  or  depression  of  the  fragments 
is  the  only  sign  which  can  be  relied  upon  to  indicate  the  existence  of 
this  accident ;  and  this  must  often  be  concealed  by  the  swelling  which 
follows  so  rapidly  wherever  the  integuments  are  severely  bruised  over 
a  superficial  bone.  This  displacement  can  scarcely  occur  in  but  two 
directions,  either  outwards  or  inwards;  since  the  attachments  of  the 
temporal  aponeurosis  above,  and  of  the  masseter  muscle  below,  must 
effectually  prevent  its  descent  or  ascent. 

Neither  motion  nor  crepitus  will  often  be  present.  In  some  few 
cases  the  difficulty  in  opening  or  shutting  the  mouth,  occasioned  by 
the  projection  of  the  fragments  towards  or  into  the  tendon  of  the  tem- 
poral muscle,  may  assist  in  the  diagnosis. 

Prognosis. — If  the  fracture  has  been  produced  indirectly  by  a  de- 
pression of  the  malar  bone,  the  prognosis  must  depend  upon  the 
amount  of  injury  done  to  the  other  bones  of  the  face;  in  itself,  the 
fracture  of  the  zygoma  cannot  be  a  matter  of  any  moment.  The  same 
remark  might  apply  also  to  any  fracture  of  the  zygoma  in  which  the 
angles  were  salient  outwards.  If,  on  the  contrary,  the  angle  is  salient 
inwards,  the  fracture  having  been  produced  by  a  blow  inflicted  directly 
upon  the  zygomatic  arch,  from  without,  or  by  a  blow  upon  the  outer 
portion  of  the  malar  bone,  it  may,  perhaps,  occasion  some  embarrass- 
ment to  the  action  of  the  temporal  muscles. 

If  the  force  which  produces  the  fracture  has  acted  more  upon  the 
temporal  portion  of  the  arch,  near  where  the  process  arises  from  the 
temporal  bone,  it  may  be  accompanied  with  a  fracture  of  the  skull, 
and  with  serious  cerebral  lesions,  as  in  one  of  the  cases  already  alluded 
to  as  having  been  noticed  by  Dupuytren. 

1  Op.  cit.,  p.  335.  2  Bulletin  de  la  Soc.  Anat.,  1810,  p.  138. 


108       FEACTURES  OF  THE  ZYGOMATIC  ARCH. 

The  abscess  which  followed  in  the  case  of  the  compound,  commi- 
nuted fracture,  quoted  from  the  same  author,  indicates  the  danger  of 
this  complication  ;  but  it  must  be  noticed  that  its  evacuation  resulted 
in  a  rapid  cure,  and  that  no  deformity  or  difficulty  in  moving  the  jaw 
remained. 

Treatment. — A  fracture,  accompanied  with  an  outward  displacement, 
and  occasioned  by  a  depression  of  the  malar  bone,  will  be  adjusted 
by  a  restoration  of  the  malar  bone  in  the  manner  already  described, 
when  speaking  of  fractures  of  the  superior  maxillary,  &c.  If  the 
fragments  are  displaced  outwards,  in  consequence  of  a  direct  blow 
from  within,  then  they  may  be  replaced  by  pressing  upon  the  project- 
ing angle.  In  this  way  Duverney  easily  reduced  the  bones  in  the 
case  which  I  have  cited. 

When  the  fragments,  in  consequence  of  a  direct  blow  from  with- 
out, have  been  driven  inwards,  and,  as  a  consequence,  serious  embar- 
rassment to  the  motions  of  the  temporal  muscle  ensues,  an  attempt 
ought  to  be  made  at  once  to  replace  them  ;  if,  however,  no  impedi- 
ment to  the  action  of  the  muscle  exists,  it  is  scarcely  necessary  to  say 
that  no  surgical  interference  will  be  required.  It  is  quite  probable, 
indeed,  that  a  slight  amount  of  embarrassment  may  be  the  result  of 
the  direct  injury  to  the  muscle  inflicted  by  the  blow,  without  reference 
to  the  displacement  of  the  bone,  and  that  a  few  days  will  suffice  to 
remedy  this  evil  entirely ;  and,  moreover,  experience  teaches  that  in 
the  case  of  a  fracture  in  other  bones,  where  the  fragments  actually 
penetrate  the  muscles  and  remain  thus  displaced,  the  points  are  gradu- 
ally absorbed,  and  rounded,  so  that  after  a  time  they  constitute  no 
impediment  to  the  action  of  the  muscles.  It  is  proper  to  infer  that 
the  same  thing  will  occur  here.  The  surgeon  may  be  reminded,  also, 
that  it  is  not  the  muscle  but  only  its  tendon  which  is  liable  to  be 
penetrated,  and  that  even  this  is  usually  protected  somewhat  by  a 
plate  of  soft  adipose  tissue  lying  between  the  tendon  and  the  arch. 

If  to  these  considerations  we  add  the  difficulties  which  we  shall  be 
likely  to  encounter  in  the  reduction,  we  shall  expect  to  find  but  few 
cases  in  which  a  resort  to  surgical  interference  will  be  necessary. 

Duverney  says  that  he  restored  a  fracture  of  this  arch,  accompanied 
with  depression,  by  pressing  against  the  zygoma  from  within  the 
mouth;  but  an  examination  of  the  interior  of  the  buccal  cavity  will 
convince  us  that  this  is  impossible  when  the  fracture  is  at  any  point 
near  the  middle  of  the  zygoma,  and  that  it  can  be  only  when  the  frac- 
ture is  at  or  near  the  junction  of  the  zygoma  with  the  body  of  the 
malar  bone  that  any  effective  pressure  can  be  made  from  this  direction. 
In  such  a  case,  we  may,  perhaps,  lift  the  portion  of  the  zygoma  re- 
maining attached  to  the  malar  bone,  by  the  same  means  which  have 
already  been  suggested  for  lifting  the  bone  itself. 

If  the  bone  is  driven  toward  the  tendon  of  the  temporal  muscle  at 
or  near  its  centre,  as  happens  almost  always,  then  if  its  restoration  be- 
comes necessary,  it  can  be  accomplished  only  by  approaching  the  bone 
from  without. 

Dupuytren  found  an  external  wound  through  which,  by  the  aid  of 
a  levator,  he  easily  restored  the  fragments  to  place. 


FRACTURES    OF    THE    LOWER    JAW.  109 

M.  Ferrier,  however,  of  the  Hospital  of  Aries,  in  a  case  brought 
before  him,  made  an  incision  through  the  integuments  down  to  the 
bone,  and  then  attempted  to  slide  underneath  the  small  extremity  of 
a  spatula;  but  the  aponeurosis  would  not  yield,  and  he  was  obliged 
to  cut  it  also.  He  was  now  able  to  lift  the  fragments  easily.  The 
wound  healed  rapidly,  and  the  patient  was  dismissed  without  any  de- 
formity.' 


CHAPTER    XII. 

FRACTURES  OF  THE  LOWER  JAW. 

Division. — Of  43  examples  of  fracture  of  this  bone  which  have 
come  under  my  observation  and  been  recorded  by  me,  not  including 
gunshot  fractures,  40  were  broken  through  some  portion  of  the  body. 

Having  made  an  analj'^sis  of  33  of  the  above  examples,  I  find  that 
13  were  broken  completely  asunder  at  two  or  more  points,  consti- 
tuting double  and  triple  fractures;  and  of  the  remaining  20,  5  were 
accompanied  with  detachment  of  portions  of  the  alveoli,  and  1  with 
detachment  of  a  considerable  frag- 
ment from  the  body.  '  Fig.  25. 

19  of  the  33  were  comminuted 
fractures.  12  were  compound;  not 
including  in  this  enumeration  sev- 
eral examples  in  which  the  partial 
or  complete  dislodgement  of  a  tooth 
might  entitle  them  to  be  called  com- 
pound. 

Four  fractures  through  or  near 
the  symphysis  were  nearly  or  quite 
vertical,  and  18  of  the  remainder 
■were  known  to  be  oblique.  Malgaigne  has  remarked,  also,  that  in 
fractures  of  the  body  of  the  bone  the  direction  of  the  obliquity  is 
generally  such  that  the  anterior  fragment  is  made  at  the  expense  of 
the  internal  face  of  the  bone,  and  the  posterior  fragment  at  the  ex- 
pense of  the  external  face;  this  latter  overriding  the  former.  Buck, 
of  New  York,  has  seen  the  fragments  in  an  opposite  condition,  requir- 
ing the  use  of  the  knife  and  the  saw  for  their  extrication.^  I  have 
myself  recorded  one  similar  example,  but  in  which  the  fragments 
were  easily  replaced. 

In  twenty  examples  of  fractures  through  the  body,  not  including 
fractures  of  the  symphysis,  the  line  of  fracture  has  been  observed  to  be 
fourteen  times  at  or  very  near  the  mental  foramen ;  twice  between  the 

•  Bulletin  des  Sciences  Med.,  torn.  x.  p.  160. 

2  New  York  Journ.  Med.,  March,  1847.      Proceedings  of  N.  Y.  Med.  and  Surg. 
Soc,  Sept.  19,  1846. 


110  FRACTUEES    OF    THE    LOWER    JAW. 

first  and  second  incisor;  three  times  behind  the  last  molar,  and  once 
between  the  last  two  molars. 

Syme,  Liston,  and  Miller  have  remarked,  also,  the  greater  fre- 
quency of  fracture  near  this  foramen,  but  Mr.  Erichsen  thinks  he  has 
seen  it  most  frequently  broken  near  the  symphysis,  between  the  lateral 
incisors  or  between  these  teeth  and  the  canine.  Boyer  observes  that 
it  is  generally  somewhat  in  front  of  the  foramen;  for  which  reason,  as 
he  thinks,  the  deotal  nerve  is  rarely  torn. 

Says  Boyer,  in  his  Traite  des  Maladies  Chirurgicales,  "A  fracture 
never  takes  place  in  the  central  point  of  the  length  of  the  jaw,  called 
the  symphysis  of  the  chin  ;  but  when  the  solution  of  continuity  occurs 
towards  the  middle  of  the  bone,  it  is  upon  one  or  the  other  side  of  the 
symphysis,  which  remains  always  upon  one  of  the  fragments."  An 
opinion  which,  however,  he  does  not  seem  always  to  have  entertained, 
since  Eicherand,  in  a  report  of  his  lectures,  has  made  him  say  that  a 
fracture  sometimes  takes  place  "near  the  chin,  but  seldom  so  as  to 
produce  the  division  of  the  symphysis  of  that  part,  though  it  be  not 
impossible."  Bat  many  surgeons  since  his  time  have  noticed  this 
fracture,  and  Malgaigne  assures  us  that  J.  Cloquet  has  demonstrated 
its  existence  upon  an  anatomical  specimen. 

Stephen  Smith,  of  New  York,  has  seen  two  examples,^  Lonsdale 
mentions  three,^  and  Gibson  has  seen  one,^  and  I  have  met  with  two, 
both  of  which  are  recorded  in  the  early  editions  of  this  book. 

Velpeau,  Fergusson,  Gibson,  Henry  Smith,  and  others,  have  re- 
marked that  a  separation  at  th6  symphysis  takes  place  usually  in  in- 
fancy or  childhood.  But  in  the  eight  examples  in  which  I  find  the 
ages  reported,  only  one,  a  case  mentioned  by  Lonsdale,  occurred  in  a 
person  as  young  as  ten  years;  in  one  of  the  cases  seen  by  myself  the 
patient  was  seventeen  years  old,  and  the  remainder  have  ranged  from 
twenty-five  years  to  sixty ;  and  the  average  age  of  all  is  thirty-two 
years. 

I  have  seen  one  example  of  a  fracture  of  the  ramus,  in  a  man  twenty- 
three  years  old,  who  had  been  struck  by  a  wooden  block  on  the  side 
of  his  ftice.  The  ramus  was  broken  just  above  the  angle,  and  the 
body  was  broken,  also,  obliquely  near  the  symphysis.  The  intercepted 
fragment  was  carried  inwards:*  and  in  May,  1869, 1  met  with  another 
simihir  case  at  Bellevue  Hospital,  in  a  woman;  a  pharyngeal  abscess 
resulted,  threatening  suffocation;  for  which  my  house  surgeon.  Dr. 
Frank  Bosworth,  performed  tracheotomy  successfully.  Ledran  men- 
tions the  case  of  a  child,  ten  or  twelve  years  old,  in  whom  the  fracture 
was  double  also;  one  fracture  having  taken  place  through  the  body, 
and  one  extending  obliquely  from  the  root  of  the  coronoid  process  to 
the  neck  of  the  condyle.  The  intercepted  fragment  was,  however,  so 
little  displaced  that  the  fracture  of  the  ramus  was  not  discovered  until 
after  death.*     Malgaigne  refers  to  this  as  the  only  example  recorded  ; 

•  New  York  Joiirn.  Med.,  Jan.  1857,  Hospital  Reports. 

2  Practical  Treatise  on  Fractures.  By  Edward  F.  Lonsdale.  London,  1838,  p.  226. 

3  Institutes  and  Practice  of  Surg.     By  Wm.  Gibson.     Philadelphia,  1841,  p.  261. 
■•  Trans.  Amer.  Med.  Assoc.    Report  on  "  Deformities  after  Fractures,"  vol.  viii. 

p.  385,  Case  17. 
6  Malgaigne,  op.  cit.,  p.  337,  from  Ledran,  Observ.  Chirurg.,  torn.  i.  obs.  viii. 


FRACTUKES    OF    THE    LOWER    JAW.  Ill 

but  Stephen  Smith,  of  the  Bellevue  Hospital,  has  met  with  it  four 
times  :  in  one  case  the  ramus  was  broken  on  both  sides;  in  two  cases 
one  ramus  only  was  broken  ;  and  in  one  the  body  was  broken  on  the 
right  side  and  the  ramus  on  the  left.^  In  two  of  these  examples  the 
fragments  were  not  displaced. 

The  coronoid  process  is  so  well  protected  by  muscles  and  by  the 
surrounding  bony  projections,  that  it  is  very  rarely  broken. 

Houzelot  mentions  a  case  in  which  a  fall  from  a  height  produced 
at  the  same  time  a  fracture  of  both  condyles,  of  both  coronoid  pro- 
cesses, and  of  the  symphysis.^ 

With  this  single  exception,  I  am  not  able  to  find  a  recorded  exam- 
ple of  a  fracture  of  this  process. 

At  least  nine  cases  have  been  reported  of  fracture  of  the  condyles, 
in  all  of  which  the  separation  occurred  through  the  neck,  viz.,  three 
by  Eibes,  two  by  Desault,  one  by  Berard,  one  by  Houzelot,  one  bv 
Bichat,  one  by  Packard,  of  Philadelphia,  and  two  by  Watson,  of  JST.  Y. 
The  fracture  always  occurring  through  the  neck  and  just  below  the 
insertion  of  the  external  pterygoid  muscle. 

According  to  Malgaigne,  the  analysis  of  these  cases,  excepting  those 
mentioned  by  Packard  and  Watson,  shows  two  classes  of  examples: 
the  one  occasioned  by  falls  or  blows  upon  the  chin,  and  producing  a 
simple  fracture  of  the  neck  of  the  condyle ;  the  other  occasioned  by 
injuries  inflicted  upon  the  side  of  the  face,  and  producing  a  fracture 
of  the  neck  on  the  side  corresponding  to  that  upon  which  the  injuries 
are  received,  and  at  the  same  time  a  fracture  of  the  body  upon  the 
opposite  side.  These  two  varieties  seem  to  be  about  equally  common. 

In  the  case  mentioned  by  Houzelot,  and  already  cited,  there  existed 
at  the  same  time  a  fracture  of  both  condyles,  of  both  coronoid  pro- 
cesses, and  at  the  symphysis.  The  man  also  whom  Watson  saw  in 
the  New  York  Hospital,  had  fallen  from  the  yard-arm  of  a  vessel, 
breaking  his  thigh  and  arm  bones  and  both  condyles  of  the  lower  jaw. 
"His  face  was  somewhat  deformed  by  the  retraction  of  the  chin  ;  the 
mouth  could  not  be  opened  so  as  to  protrude  the  tongue  to  any  great 
extent  beyond  the  teeth,  and  the  teeth  of  the  upper  and  lower  jaws 
could  not  be  brought  into  contact.  Iq  attempting  to  move  the  jaw, 
the  patient  experienced  pain  and  crepitation  just  in  front  of  the  ears; 
the  crepitation  could  easily  be  felt  by  placing  the  fingers  over  the 
fractured  condyles.  Nothing  was  done  for  the  fractures  of  the  jaw. 
In  a  few  weeks  the  rubbing  of  the  broken  surfaces  and  attendant  sore- 
ness ceased  to  trouble  him  ;  but  the  shape  of  the  jaw,  and  difficulty  of 
opening  the  mouth  to  any  great  extent,  still  remained  unaltered."^ 

Etiology. — The  causes,  in  such  cases  as  I  have  myself  investigated, 
seem  generally  to  have  been  direct  blows,  in  most  instances  inflicted 
by  a  club,  or  by  the  kick  of  a  horse;  in  two  examples  the  blow  was 
inflicted  by  the  fist.  I  have  also  seen  a  fracture  immediately  in  front 
of  the  right  cuspid,  in  a  lad  eight  years  of  age,  produced  by  being 
pressed  between  two  wagons,  the  pressure  being  made  upon  the  two 

'  New  York  Journ.  of  Med.,  Jan.  1857.     Bellevue  Hosp.  Reports. 

2  Malgaigne,  op.  cit.,  p.  400. 

»  New  York  Jouru.  of  Med.,  Oct.  1840.     Hospital  Reports. 


112  FEACTURES    OF    THE    LOWER    JAW. 

angles  of  the  jaw.  In  ten  of  eleven  cases  mentioned  by  Stephen  Smith, 
the  causes  were  direct  blows.  Examples  of  fracture  of  the  inferior 
maxilla  from  indirect  blows  have,  however,  been  mentioned  by  other 
surgeons,  the  angles  of  the  bone  being  pressed  together  by  the  pas- 
sage of  a  wheel,  and  the  fracture  taking  place  usually  towards  the 
symphysis. 

We  have  already  alluded  to  the  observation  of  Malgaigne,  that  frac- 
tures of  the  condyles  belong  to  two  classes;  the  one  being  occasioned 
by  falls  upon  the  chin,  and  the  other  by  blows  upon  the  side  of  the 
face;  the  former  acting  as  a  counter  force,  and  the  latter  as  a  direct. 

The  coronoid  process  can  only  be  broken  by  a  direct  blow. 

Symptoms. — Fractures  of  the  body  of  the  bone  are  characterized  by 
the  usual  signs  of  fracture  elsewhere,  namely,  displacement,  mobility, 
crepitus,  and  pain. 

The  displacement  is  generally  present;  but  its  direction  and  amount 
vary  according  to  the  situation  and  course  of  the  fracture,  and  also 
according  to  the  violence  and  direction  of  the  force  producing  the 
fracture.  I  have  seen  several  cases  unaccompanied  with  displacement, 
and  one  of  these  I  think  ought  to  be  regarded  as  an  example  of  a 
partial  fracture. 

A  lad,  set.  9,  was  kicked  by  a  horse  on  the  22d  of  June,  1858,  the 
blow  being  received  on  the  right  side  of  the  jaw.  I  saw  him  very 
soon  after  the  accident,  but  could  not  detect  any  fracture,  only  the 
body  of  the  jaw  seemed  to  be  bent  in.  On  the  third  day,  however, 
while  endeavoring  to  straighten  the  jaw  by  violent  pressure  from 
within  outwards,  I  detected  a  feeble  crepitus,  which  on  more  careful 
examination  proved  to  be  opposite  the  second  incisor  of  the  right 
side.  I  was  also  able  to  detect  a  slight  motion  at  the  same  point.  It 
was  found  impossible  to  rectify  the  bending,  and  no  farther  efforts 
were  employed.  At  this  moment,  after  a  lapse  of  nearly  a  year,  the 
natural  curve  is  partially  but  not  completely  restored. 

Ledran  and  other  surgeons  have  also  seen  examples  where  neither 
the  periosteum  nor  mucous  membrane  was  torn. 

Generally,  in  fractures  of  the  body,  the  anterior  fragment  is  de- 
pressed; and  Malgaigne  affirms  that  where  an  overlapping  occurs,  the 
anterior  fragment  lies,  generally,  within  the  posterior;  a  fact  which 
he  explains  by  the  direction  which  the  line  of  fracture  usually  takes, 
namely,  from  without,  inwards  and  backwards,  as  we  have  already 
mentioned.  In  one  instance,  reported  by  me  to  the  Amer.  Med.  Assoc, 
where  the  jaw  was  broken  at  the  symphysis  and  also  on  both  sides 
through  the  body,  the  central  fragments  were  found,  after  about  four 
weeks,  lifted  two  lines  above  the  lateral  fragments,  and  also  slightly 
carried  backwards.*  I  have  twice  also  met  with  examples  in  which 
the  posterior  fragments  were  inclined  to  fall  inwards  toward  the  mouth, 
a  circumstance  which  seemed  to  indicate  that  the  course  of  the  obliquity 
was  in  a  direction  opposite  to  that  which  Malgaigne  has  observed  to 
be  most  frequent.  In  each  of  these  examples  the  jaw  was  broken 
upon  both  sides,  by  blows  inflicted  with  a  club,  and  the  fractures  were 

'  Trans.  Amer.  Med.  Assoc,  vol.  viii.  p.  380,  1855,  Case  6. 


FRACTURES    OF    THE    LOWER    JAW.  113 

situated  well  back,^  It  is  possible,  however,  that  the  position  of  the 
frao-ments  was  due  rather  to  the  direction  and  force  of  the  impression 
than  to  the  direction  of  the  line  of  fracture. 

As  to  the  action  of  the  muscles  in  the  production  of  displacement, 
Boyer,  S.  Cooper,  Erichsen,  and  Malgaigne  have  observed  that  their 
action  upon  the  anterior  fragment  is  greater  in  proportion  as  the  frac- 
ture is  nearer  the  symphysis,  and  less  in  proportion  as  it  approaches 
the  angle.  So  that  in  the  former  case  the  attempt  to  close  the  mouth 
is  sometimes  attended  with  a  depression  of  the  anterior  fragment, 
causing  a  separation  of  the  fragments  at  their  alveolar  margins ;  while 
in  the  latter  case  the  attempt  to  close  the  mouth  forcibly  is  occasion- 
ally attended  with  separation  of  the  fragments  along  the  line  of  the 
base. 

While  I  am  not  prepared  to  deny  the  accuracy  of  these  observations, 
it  is  proper  to  notice  that  Liston  finds  the  greatest  displacement  when 
the  fracture  is  opposite  the  first  molar,  and  I  must  confess  that  the  fact, 
as  stated  by  Boyer  and  others,  does  not  seem  to  admit  of  a  satisfactory 
explanation;  since  the  number,  and  consequently  the  power,  of  the 
muscles  which  act  upon  the  anterior  fragment  from  below  is  greater 
in  proportion  as  the  line  of  fracture  is  farther  back.  These  muscles, 
namely,  the  digastricus,  the  genio-hyo-glossus,  and  the  mylo-hyoideus, 
with  several  other  muscles  which  act  less  directly,  all  tend  to  depress 
the  anterior  fragment,  and  in  some  slight  degree  to  carry  it  backwards, 
a  direction  which,  indeed,  it  usually  takes,  and  which  it  would  pro- 
bably always  take  if  left  alone  to  the  action  of  the  muscles.  If  the 
fracture  has  occurred  through  the  angle,  or  at  any  point  within  the 
attachments  of  the  masseter  muscle,  the  action  of  those  fibres  of  this 
muscle  which  remain  connected  with  the  anterior  fragment  will  suffi- 
ciently explain  the  fact  that  it  is  not  now  so  easily  depressed  below 
the  level  of  the  posterior  fragment ;  while  the  separation  of  the  frag- 
ments along  the  line  of  the  base  when  an  attempt  is  made  to  close 
the  jaw  forcibly,  is  probably  due  to  the  loosening  and  partial  dislodge- 
ment  of  some  of  the  molars,  which,  being  pressed  upwards,  act  as  a 
pivot  upon  which  the  fragments  are  made  to  bend. 

Boyer  affirms,  also,  that  "the  fractured  portions  are  never  deranged 
so  as  that  one  passes  on  the  other,  or  in  the  direction  of  their  length ; 
for  the  action  of  none  of  the  muscles  of  the  lower  jaw  is  parallel  to 
the  axis  of  that  bone ;  besides,  its  extremities  are  retained  in  the 
glenoidal  cavities  of  the  temporal  bones,"  But  this  theory  is  too  ex- 
clusive, since  the  fragments  may  have  become  displaced  in  any  direc- 
tion independently  of  the  muscular  action.  Moreover,  the  action  of 
the  muscles  attached  to  the  anterior  fragment,  although  not  parallel  to 
the  axis  of  the  bone,  does  somewiiat  favor  a  displacement  in  this 
direction ;  and  the  action  of  the  pterygoid  muscles  upon  the  posterior 
fragment  still  farther  favors  this  form  of  displacement. 

An  overlapping  of  the  fragments  in  the  direction  of  the  axis  is,  in 
simple  fractures,  no  doubt,  exceptional,  and  in  such  examples  as  I  have 
seen,  it  was  very  trivial.     It  occurred  in  case  "three"  of  my  "Eeport," 

'  Ibid.,  Cases  1  and  10. 


114  FKACTURES    OF    THE    LOWER    JAW. 

the  fracture  being  near  the  mental  foramen;  in  case  "two,"  the  frac- 
ture being  just  anterior  to  the  last  molar;  and  also  in  case  "six," 
where  the  bone  had  been  broken  through  the  centre  of  the  body  on 
both  sides  and  through  the  symphysis;  but  in  neither  case  did  the 
overlapping  exceed  two  or  three  lines,  and  it  was  always  easily  over- 
come. 

The  mobility  of  the  fragments  is  not  so  striking  in  these  accidents 
as  in  fractures  of  the  long  bones,  yet  it  is  generally  sufficiently  marked, 
and  especially  where  the  bone  is  broken  upon  both  sides  at  the  same 
time.  If  onlv  one  side  is  broken,  both  motion  and  crepitus  will  be 
most  easily  detected  by  lateral  pressure  upon  the  posterior  fragment, 
which,  being  the  smallest  and  the  least  supported  by  antagonizing 
muscles,  will  be  found  to  be  the  most  movable.  If  the  fracture  is 
upon  both  sides,  mobility  and  crepitus  will  be  most  readily  developed 
by  seizing  upon  the  anterior  fragment  and  moving  it  gently  up  and 
down,  while  the  finger  rests  upon  the  alveolus  within  the  mouth. 

Sometimes  a  slight  swelling  or  tenderness  at  some  point  of  the 
dental  arcade,  or  the  loosening  or  complete  dislodgement  of  a  tooth, 
will  indicate  the  point  of  fracture. 

Pain,  especially  when  the  fragments  are  moved,  is  here  more  con- 
stant than  in  most  other  fractures,  owing  perhaps,  in  part,  to  the 
superficial  position  of  the  bone,  which  renders  the  soft  parts  lying  over 
it  more  liable  to  injury  from  the  causes  of  fracture ;  but  also,  in  part, 
to  the  lesions  which  the  inferior  dental  nerve  may  have  suffered.  It 
is,  indeed,  a  matter  of  surprise  that  injury  to  this  nerve  does  not 
oftener  seriously  complicate  these  accidents,  coursing,  as  it  does, 
through  so  large  a  portion  of  the  angle  and  body  of  the  bone.  One 
might  naturally  suppose  that  its  complete  disruption  would  often 
occasion  paralysis  of  those  portions  of  the  face  to  which  it  is  finally 
distributed,  and  that  its  partial  lesions  and  contusions  would  create, 
in  many  cases,  the  most  acute  and  constant  suffering.  It  is  rare,  how- 
ever, that  we  have  present  an  amount  of  pain  which  might  not  be 
attributed  to  a  severe  shock,  or  a  slight  strain  upon  its  fibres.  I  have 
myself  never  seen  any  extraordinary  suffering  distinctly  attributable 
to  an  injury  of  the  dental  nerve  after  fracture,  nor  any  degree  of  facial 
paralysis.  Rossi  relates  a  case  in  which  convulsions  followed  this 
accident,  and  in  which,  as  a  final  remedy,  he  proposed  to  expose  and 
bisect  the  nerve;  and  Flajani  saw  a  patient,  whose  jaw  had  been 
broken,  die  in  convulsions  on  the  tenth  day,  the  muscular  contractions 
having  commenced  as  early  as  the  fourth  day  after  the  accident.  The 
autopsy  disclosed  a  rupture  of  the  dental  nerve,  but  no  injury  to  the 
brain. 

These  two  examples  are,  as  far  as  I  know,  all  which  our  records 
supply,  in  which  grave  results  have  been  attributed  to  lesions  of  this 
nerve;  and  even  here  some  doubt  must  remain  whether  the  symptoms 
were  not  quite  as  much  due  to  the  immediate  injury  done  to  the  brain 
as  to  the  nerve. 

Boyer  explained  the  infrequency  of  severe  injury  to  the  dental 
nerve  by  the  supposition  that  the  "  greater  part  of  these  fractures  take 
place  between  the  symphysis  and  the  foramen  by  which  this  nerve 


FRACTURES    OF    THE    LOWER    JAW.  115 

comes  out."  An  opinion  which  may  be  correct,  but  needs  confirma- 
tion. I  have  seen  the  body  or  angle  broken  at  points  posterior  to  the 
mental  foramen,  and  where  the  nerve  lies  within  its  bony  canal, 
twelve  times,  and  in  front  of  the  mental  foramen  eight  times ;  at 
other  times  the  point  of  fracture  has  not  been  noted  with  such  accu- 
racy as  to  enable  me  to  say  whether  it  was  in  front  or  behind  the 
foramen. 

I  suspect  that  a  better  explanation  may  be  found  in  the  fact  that  the 
fragments  seldom  overlap,  to  any  appreciable  extent,  and  that  even 
the  displacement  in  the  direction  of  the  diameters  of  the  bone  is  gene- 
rally inconsiderable ;  or  if  it  does  exist,  the  fragments  are  easily  and 
promptly  replaced. 

If  the  displacement  is  sufficient  to  occasion  a  complete  disruption 
of  the  nerve,  some  degree  of  temporary  paralysis  in  the  portions  of 
the  face  supplied  by  it  must  be  inevitable;  and,  perhaps,  this  occurs 
oftener  than  it  has  been  noticed,  since,  during  the  confinement  of  the 
jaw  by  dressings,  it  is  not  likely  to  be  observed,  and  after  the  lapse  of 
a  few  weeks  it  will  probably  cease  altogether. 

Boyer  remarks  that  when  it  is  torn,  "the  square  and  triangular 
muscles  of  the  chin  are  paralyzed.  The  skin  of  that  part  and  the  in- 
ternal membrane  of  the  under  lip  preserve  their  sensibility,  which  it 
appears  they  owe  to  some  threads  of  the  portio  dura  of  the  seventh 
pair;  but  the  paralysis  of  these  muscles  does  not  prove  of  itself  that 
the  jaw  is  fractured."  Boyer  has,  however,  noticed  this  result  but 
once,  and  then  in  a  case  where  the  bone  was  broken  upon  both  sides 
and  the  soft  parts  greatly  contused.  The  triangular  and  square  mus- 
cles were  paralyzed,  in  consequence  of  which  there  was  a  slight  con- 
tortion of  the  mouth.  A.  Berard  has  also  mentioned  a  case  of  vertical 
fracture  occurring  between  the  second  and  third  molars,  without  dis- 
placement, which  was  accompanied  with  complete  insensibility  of  the 
lip  on  the  same  side  throughout  the  space  comprised  between  the 
commissure  and  the  median  line,  and  between  the  free  border  of  the 
lip  and  the  chin.     The  paralysis  disappeared  after  a  few  days.^ 

To  these  signs  now  enumerated,  we  may  add  as  occasional  com- 
plications, rather  than  as  diagnostic  symptoms,  salivation,  swelling  of 
the  submaxillary  and  sublingual  glands,  abscesses,  necrosis,  &c.  If 
the  blow  has  been  vertical  upon  the  chin,  and  the  direction  of  its 
force  has  been  towards  the  articulations,  the  bony  structure  of  the 
ear,  and  even  the  brain,  may  have  suffered  serious  lesions,  which  may 
be  indicated  by  a  deafness  or  a  roaring  in  the  ears,  by  bleeding  from 
the  external  meatus,  and  by  fatal  coma.  Tessier  saw  a  man  who  had 
received  the  kick  of  a  horse  exactly  upon  the  centre  of  the  chin, 
breaking  the  bone  on  both  sides,  and  who,  in  consequence,  bled  freely 
from  his  ears;^  and  Alix  relates  the  case  of  a  young  man  who,  fall- 
ing from  a  height  and  striking  upon  his  chin,  had  broken  his  jaw. 
Insensibility  immediately  followed  ;  convulsions  also  ensued  upon  the 
fourth  day,  and  he  died  upon  the  sixth.^ 

1  Malgaigne,  from  Gazette  des  Hopitaux,  10  Aout,  1841. 
Malgaigne,  pp.  383  and  380,  from  Journ.  de  Med.,  178fl,  tom.  Ixxix.  p.  346. 
Ibid.,  p.  386,  from  Alix,  Observata  Cliir.,  fascic.  1,  obs.  10. 


116  FRACTUKES    OF    THE    LOWER    JAW. 

If  the  fracture  is  at  the  symphysis,  it  is  generally  vertical,  and  either 
fragment  may  be  found  slightly  displaced  upwards  or  downwards. 
In  one  of  the  examples  seen  by  myself,  the  left  fragment  fell  three 
lines  below  the  right,  and  in  another  the  right  side  had  fallen  about 
one  line.  In  a  case  mentioned  by  Syme  there  was  scarcely  any  dis- 
placement.* Liston  remarks  that  it  is  usually  slight,  Erichsea  and 
B.  Cooper  have  observed  the  same. 

Signs  which  indicate  a  fracture  through  the  angle  have  already 
been  sufficiently  considered  when  speaking  of  fractures  of  the  body  ; 
from  which  it  only  differs  in  the  less  degree  of  displacement,  and  in 
the  fact  that  the  posterior  fragments  are  a  little  more  prone  to  fall  in- 
wards towards  the  mouth.  I  have  noticed,  also,  that,  owing  probably 
to  the  loosening  and  partial  dislodgement  of  the  last  molar,  it  is  some- 
times difficult  to  close  the  mouth,  the  same  as  in  the  fractures  a  little 
farther  forwards. 

In  each  of  the  two  examples  of  fracture  of  the  ascending  ramus 
which  I  have  seen,  the  bone  being  broken  also  through  its  body,  the 
fracture  of  the  ramus  was  recognized  by  both  crepitus  and  mobility. 

As  to  the  signs  which  indicate  a  fracture  of  the  coronoid  process,  I 
am  only  able  to  infer  them  from  its  anatomical  relations.^  There  must 
be  some  embarrassment  in  the  motions  of  the  jaw,  occasioned  by  the 
detachment  of  a  portion  of  the  fibres  of  the  temporal  muscle ;  and 
it  is  probable  that  an  examination  by  the  finger  within  the  mouth 
would  readily  detect  mobility  and  displacement. 

A  fracture  through  the  neck  of  the  condyle  is  characterized  by  pain 
at  the  seat  of  fracture,  especially  recognized  when  an  attempt  is  made 
to  open  or  shut  the  mouth,  by  embarrassment  in  the  motions  of  the 
jaw,  by  crepitus,  which  may  usually  be  felt  or  heard  by  the  patient 
himself,  by  mobility  and  displacement. 

The  upper  fragment,  if  disengaged  from  the  lower,  is  drawn  for- 
wards, upwards,  and  inwards,  by  the  action  of  the  pterygoideus  exter- 
nus;  and  it  is  felt  not  to  accompany  the  movements  of  the  lower 
fragment. 

The  lower  fragment  is  at  the  same  time  drawn  upwards,  in  conse- 
quence of  which  the  lower  part  of  the  face  is  distorteds';  a  circum- 
stance first  noticed  by  Ribes,  and  which  supplies  an  important  diag- 
nostic mark  between  a  fracture  of  one  condyle  and  a  dislocation.  In 
dislocation,  the  chin  is  commonly  thrown  to  one  side,  but  it  is  to  the 
side  opposite  that  on  which  the  dislocation  has  occurred,  while  in  frac- 
ture the  chin  is  drawn  to  the  same  side. 

Prognosis. — Physick,  of  Philadelphia,  saw  a  case  of  non-union  of 
the  body  of  this  bone,  which  had  existed  nine  months.*  Dupuytren 
mentions  a  case  which  had  existed  three  years.^  Stephen  Smith,  of 
New  York,  reports  a  case  of  fracture  of  both  the  body  and  the  ramus, 
in  a  man  forty-five  years  old.  The  severity  of  the  injury,  with  the 
supervention  of  delirium  tremens,  prevented  the  application  of  dress- 
ings until  the  thirteenth  day.  On  the  twentieth  day  about  a  pint  of 
blood  was  lost  by  hemorrhage  from  the  seat  of  fracture.     He  re- 

'  Amer.  Journ.  Med.  Sci.,  vol.  xviii.  p.  243. 

2  Phila.  Med.  and  Surg.  Journ.,  vol.  v.  *  Lejons  Orales. 


FRACTURES    OF    THE    LOWER    JAW.  117 

mained  in  the  hospital  one  hundred  and  thirty-seven  days,  and  was 
finally  discharged,  the  fragments  not  having  yet  united.*  I  have 
seen  one  example  of  fibrous  union  in  the  case  of  a  man  who  broke 
the  body  of  the  jaw  by  a  fall  upon  his  chin.  Malgaigne  says  that 
Boyer  has  seen  several  examples,  but  I  know  of  no  other  cases,  unless 
as  the  result  of  gunshot  injuries,  which  have  been  recorded.  In  no 
instance  of  a  simple  fracture  which  has  come  under  my  personal  care, 
has  the  bone  refused  finally  to  unite,  although  I  have  seen  the  union 
delayed  six,  seven,  ten,  and  even  eleven  weeks  or  more.*  In  three  of 
these  cases  the  fractures  were  either  compound  or  comminuted  ;  but 
in  one  case  the  fracture  was  simple,  the  delay  in  the  union  being  due 
to  a  feeble  condition  of  the  system,  and  in  part,  perhaps,  to  neglect 
of  proper  treatment.  Since  the  commencement  of  the  late  war  I 
have  met  with  several  examples  of  non-union,  and  of  fibrous  union, 
after  gunshot  fractures;  but,  so  far  as  I  can  remember,  in  all  of  these 
cases  necrosis  existed,  or  some  portions  of  the  bone  had  been  carried 
away. 

The  infrequency  of  non-union  after  this  fracture  is  a  fact  worthy 
of  especial  attention,  because  of  the  extreme  difficulty,  if  not  actual 
impossibility,  in  many  cases,  of  wholly  preventing  motion  between 
the  fragments,  by  any  mode  of  dressing  yet  devised.  Any  one  who 
has  observed  attentively,  must  have  seen,  not  only  that  his  dressings 
are  more  often  found  disturbed  and  loosened  than  in  the  case  of  al- 
most any  other  fracture,  unless  it  be  the  clavicle,  and  thus  the  frag- 
ments have  been  through  all  the  treatment  subjected  to  frequent 
changes  of  position  ;  but,  also,  that  even  while  the  dressings  remain 
snugly  in  place,  the  patient  seldom  is  able  to  perform  the  necessary 
acts  of  deglutition,  or  to  speak,  even,  without  inflicting  some  slight 
motion  upon  the  fragments. 

Indeed,  the  rapidity  as  well  as  certainty  with  which  this  bone 
unites,  has,  I  think,  been  observed  by  other  surgeons,  and  I  have  my- 
self noticed  one  instance,  in  an  adult  person,  in  which  the  bone  was 
immovable  at  the  seat  of  fracture  on  the  seventeenth  day,  and  per- 
haps earlier.  In  other  instances,  the  union  has  been  speedily  effected 
after  the  removal  of  all  dressings. 

The  amount  of  deformity  resulting,  also,  from  these  fractures  is 
usually  very  trifling,  whatever  treatment  has  been  adopted.  Only 
eight  of  the  united  fractures,  seen  and  recorded  by  me,  are  imperfect, 
and  in  none  of  these  is  the  imperfection  such  as  to  be  noticed  in  a 
casual  examination  of  the  face.  The  deformity  which  is  usually  found, 
is  a  slight  irregularity  of  the  teeth,  produced,  in  most  cases,  by  a  fall- 
ing of  the  anterior  fragment,  but  in  one  case  by  a  slight  elevation  of 
the  anterior  fragment.  But  even  this  does  not  always  interfere  with 
mastication,  and  would  often  pass  unnoticed  by  the  patient  himself. 
It  is  probable,  too,  that  time,  and  the  constant  use  of  the  lower  jaw  in 
mastication,  will  gradually  effect  a  marked  improvement  in  the  ability 
to  bring  the  opposing  teeth  into  contact.  I  think  I  have  observed 
this  in  several  instances. 

1  Smith,  New  York  Journ.  of  Med.  and  Surg.,  Jan.  1857. 

2  My  Report  on  Deformities  after  Frac,  Cases  2,  14,  15,  18. 


118  FRACTURES    OF    THE    LOWER    JAW. 

Chelius  remarks  that  in  "double  or  oblique  fractures  it  is  very  dif- 
ficult to  keep  the  broken  ends  in  their  proper  place ;  deformity  and 
displacement  of  the  natural  position  of  the  teeth  commonly  remain." 

In  the  second  example  of  fracture  through  the  symphysis  mentioned 
by  me,  the  left  fragment  remained  slightly. elevated,  and  the  patient 
could  not  close  his  teeth  perfectly,  yet  he  could  close  them  sufficiently 
for  the  purposes  of  mastication.  It  is  probable,  however,  that  ordi- 
narily no  difficulty  will  be  experienced  in  accomplishing  a  perfect 
cure  when  the  separation  has  taken  place  only  at  the  symphysis. 

In  fractures  of  the  condyles,  more  care  is  requisite  to  retain  the  frag- 
ments in  apposition,  and  sometimes  it  may  be  found  to  be  impossible. 
Eicherand  mentions  the  case  of  a  man,  who,  having  been  three  months 
in  the  "  Hopital  de  la  Charite,"for  a  double  fracture  of  the  lower  jaw, 
one  fracture  being  near  the  middle,  and  the  other  near  the  right  con- 
dyle, left  before  the  cure  was  complete.  Seven  or  eight  months  after, 
he  called  upon  Boyer,  who  extracted  from  a  fistula  in  the  meatus  audi- 
torius  exterrius,  a  bony  mass  which  had  evidently  the  form  of  the 
condyle.'  Bichat  mentions  a  similar  case  as  having  come  under  the 
observation  of  Desault;^  possibly  it  was  the  same  which  Boyer -saw. 
Eibes  says  that  a  Parisian  surgeon  treated  a  double  fracture  of  the  jaw 
in  a  gentleman,  one  fracture  being  through  the  body  and  the  other 
through  the  neck  of  the  condyle ;  and,  in  spite  of  the  most  assiduous 
and  skilful  attention,  the  patient  recovered  with  a  lateral  distortion  of 
the  jaw,  occasioned  by  the  displacement  of  the  fragments.^  Ribes 
himself  had  to  treat  an  accident  of  a  similar  character,  and,  notwith- 
standing all  his  care,  the  result  was  the  same  as  in  the  other  example 
just  cited.^  Fountain,  of  Iowa,  was  much  more  fortunate,  having 
made  a  complete  and  perfect  cure.' 

The  proximity  of  this  fracture  to  the  articulating  surface  may  occa- 
sion contraction  of  the  ligaments  about  the  joint ;  and  a  degree  of 
embarrassment  to  the  motions  of  the  jaw  has  followed  in  the  expe- 
rience of  Desault  and  others,  even  when  the  cure  has  been  most  com- 
plete ;  but  this  has  usually  remained  only  for  a  short  period. 

Sanson  asserts  that  when  the  coronoid  process  is  broken,  the  frac- 
ture never  unites;  but  that  mastication  is  performed  very  well,  the 
masseter  and  pterygoid  muscles  then  fulfilling  the  office  of  the  tem- 
poral.® 

Ireatment. — The  few  attempts  which  I  have  made  to  restore  a  com- 
pletely dislocated  tooth  to  its  socket,  or  to  retain  it  in  place  when  very 
much  loosened,  have  generally  resulted  in  its  removal  at  some  later 
day,  and  especially  where  the  fracture  has  been  near  the  angle  and  a 
molar  has  been  disturbed.  I  believe  it  would  be  better  practice 
always  to  remove  the  molars  under  these  circumstances,  unless  they 
remain  attached  to  the  alveoli,  and  cannot  be  removed  without  bring- 

•  Boyer,  Lectures  on  Dis.  of  Bones,  p.  53,  Phila.  ed.,  1805. 

2  Desauit,  Treatise  on  Fractures  and  Luxations,  Phila.  ed.,  1805,  p.  3. 
'  Malgaigne,  op.  cit.,  p.  402. 

*  Ibid.,  p.  403. 

^  Fountain,  New  York  Jour.  Med.,  Jan.  1860. 

6  S.  Cooper's  First  Lines,  Amer.  ed.,  1844,  vol.  ii.  p.  311. 


FEACTUEES    OF    THE    LOWEE    JAW.  119 

ing-  tliem  away  also  ;  and  this,  whether  the  loosened  teeth  are  -situated 
in  the  line  of  fracture  or  not.  It  is  seldom  that  they  can  be  made 
again  to  occupy  their  sockets  perfectly,  and  where  the  teeth  are  in  the 
line  of  the  fracture,  the  attempt  to  restore  them  to  place  will  sometimes 
prevent  the  proper  adjustment  of  the  fragments.  In  cases,  also,  in 
which  the  teeth  farther  forwards  are  completely  dislodged  at  the  seat 
of  fracture,  it  is  scarcely  worth  while  to  replace  them. 

As  to  those  teeth  whose  loosened  condition  is  due  only  to  a  splitting 
of  the  alveoli  in  a  longitudinal  direction,  the  same  rule  will  not  always 
apply.  Sometimes,  after  a  careful  readjustment,  the  fragments  will 
reunite,  and  the  teeth  remain  firm. 

If  the  bone  is  chipped  oft'  upon  the  outside,  through  or  near  the 
line  of  the  sockets,  the  teeth  may  not  be  always  much  disturbed,  and 
the  loss  of  the  fragments  may  be  of  less  consequence,  nor  have  I  gene- 
rally succeeded  in  saving  them ;  yet  if  they  remain  adherent  to  the 
soft  parts,  it  is  proper  to  make  the  attempt. 

The  expedients  to  which  surgeons  have  resorted  for  the  purpose  of 
retaining  in  place  the  fragments,  when  the  bone  is  broken  through  its 
body,  may  be  arranged  under  the  names  of  ligatures,  splints,  bandages, 
and  slings. 

The  ligature  has  been  applied  both  to  the  teeth  and  to  the  bone 
itself  Thus,  in  an  oblique  fracture  near  the  angle,  where  the  frao-- 
ments  could  not  otherwise  be  prevented  from  falling  inwards,  Baudens 
passed  a  strong  ligature,  formed  of  thread,  around  the  fragments  and 
in  immediate  contact  with  them,  tying  the  ligature  over  the  teeth 
within  the  mouth.  No  accident  followed,  and  on  the  twenty-third 
day,  when  he  removed  the  ligature,  the  bone  had  united  firmly  and 
smoothly.^ 

In  the  case  of  the  fracture  of  the  inferior  maxilla,  reported  by  Dr. 
Buck,  to  the  New  York  Pathological  Society,  and  already  referred  to, 
the  bone  "  was  broken  between  the  two  incisor  teeth  of  the  left  side ; 
the  part  of  the  bone  on  the  left  of  the  fracture  was  driven  in,  and 
interlocked  behind  the  end  of  the  right  portion,  so  as  to  be  separated 
by  a  finger's  breadth.  Finding  it  impossible  otherwise  to  reduce  the 
fracture.  Dr.  B.  dissected  off"  the  under  lip,  so  as  to  expose  the  fracture. 
He  found  that  the  right  anterior  portion  of  the  fractured  bone  ter- 
minated in  an  angular  projection  as  far  as  on  a  line  below  the  left 
angle  of  the  mouth.  The  lip  was  then  divided  to  the  chin,  and  the 
soft  parts  holding  the  fragments  together  incised.  A  chisel  was  then 
insinuated  behind  the  projecting  angle  of  the  bone,  while  it  was  being 
excised  by  the  metacarpal  saw.  When  the  bone  was  restored  to  its 
natural  position,  it  was  found  so  apt  to  become  displaced,  that  holes 
were  drilled  at  the  lower  angle  of  the  fracture,  and  adjustment  main- 
tained by  wiring  them  together,  the  wire  passing  out  through  the 
lower  angle  of  the  wound.  Sutures  and  adhesive  straps,  with  a  band- 
age, were  employed  to  maintain  the  adjustment  of  the  parts.  So  far 
the  patient  has  done  well,  being  supported  by  liquid  nourishment 
introduced  through  a  tube  passed  through  the  space  left  by  one  of 

'  Malgaigne,  op.  cit.,  p.  398. 


120  FKACTURES    OF    THE    LOWER    JAW, 

the  incisors,  which,  on  account  of  its  looseness,  was  removed."^  Dr. 
E.  A.  Kinloch,  of  Charleston,  S.  C,  has  reported  a  similar  case,  in 
which  he  employed  successfully  the  wire.^ 

In  May,  1858,  while  trephining  at  the  angle  of  the  jaw  for  the  pur- 
pose of  cutting  out  a  portion  of  the  dental  nerve  in  a  patient  suflfering 
from  neuralgia,  I  accidentally  broke  the  jaw  in  two  at  the  point  at 
which  the  trephine  was  applied.  I  immediately  bored  a  hole  in  the 
opposite  extremities  of  the  two  fragments,  and  fastened  them  together 
with  a  silver  wire,  by  which  I  was  able  to  maintain  complete  appo- 
sition, and  in  three  weeks  the  union  was  accomplished,  the  wire  sepa- 
rating and  falling  out  of  itself.     No  splints  were  ever  used.^ 

With  these  exceptions,  so  far  as  I  am  aware,  the  ligature  has  been 
employed  as  a  means  of  retention  only,  by  fastening  it  upon  the  teeth, 
either  upon  those  which  are  situated  on  the  opposite  sides  of  the  frac- 
ture, or  upon  others  a  little  more  remote,  or  upon  the  corresponding 
teeth  of  the  upper  jaw,  or  upon  the  teeth  on  the  opposite  sides  of  the 
same  jaw. 

Ordinarily  the  ligature,  composed  of  either  fine  gold,  platinum,  or 
silver  wire,  or  of  firm  silk  or  linen  threads — (Celsus  advised  the  use 
of  horsehair) — has  been  applied  to  the  two  teeth  on  the  opposite  sides 
of  the  fracture,  or  if  these  have  not  been  sufficiently  firm,  to  the  next 
teeth.  This  practice,  recommended  first  by  Hippocrates,  has  received 
the  occasional  sanction  of  Ryft",  Walner,  Chelius,  Lizars,  Erichsen, 
Miller,  B.  Cooper,  Skey,  and  others,  but  by  Boyer,  Gibson,  and  Mai- 
gaigne  it  has  been  disapproved. 

Dr.  S.  G.  Ellis,  of  New  York,  as  we  have  already  seen,  has 
treated  a  fracture,  occurring  through  the  symphysis,  in  an  adult,  by 
placing  the  mainspring  of  a  watch  within  the  dental  arcade,  and 
securing  it  in  place  with  silver  wire.  The  mouth  was  kept  closed  by 
bandages  carried  under  the  chin.  The  fragments  united  with  only  a 
.slight  vertical  displacement.* 

Dr.  George  Hayward,  of  Boston,  surgeon  to  the  Massachusetts 
General  Hospital,  says :  "When  the  bone  is  not  comminuted  and  there 
are  teeth  on  each  side  of  the  fracture,  the  ends  of  the  bone  can  be 
kept  in  exact  apposition  by  passing  a  silver  wire  or  strong  thread 
around  these  teeth  and  tying  it  tightly.  In  several  cases  of  fracture 
of  the  jaw,  in  which  the  bone  was  broken  in  one  place  only,  I  have,  in 
the  course  of  the  last  few  years,  adopted  this  practice  with  entire  suc- 
cess, and  without  the  aid  of  any  other  means.  It  will  be  found  very 
useful,  also,  as  an  auxiliary,  in  more  severe  cases,  in  which  it  may  be 
required  to  use  splints  and  bandages,  or  to  insert  a  piece  of  cork 
between  the  jaws,  as  recommended  by  Delpech.  It  requires  some 
mechanical  dexterity  to  apply  the  thread  neatly;  but  in  large  cities 
we  can  avail  ourselves  of  the  skill  of  dentists  for  this  purpose."*     I 

1  New  York  Journ.  of  Med.,  &c.,  March,  1847,  p.  211. 

*  Kinloch,  Am.  Journ.  Med.  Sci.,  July,  1859,  p.  67. 

*  Buffalo  Med.  Journ.,  vol.  xiv.  p.  148. 

*  Trans.  Amer.  Med.  Assoc.     My  report  on  "Defor.,"   &c.,  vol.  viii.  p.  383, 
Case  14. 

Boston  Med.  and  Surg.  Journ.,  vol.  xix.  p.  133,  1838. 


FRACTURES    OF    THE    LOWER    JAW.  121 

have  myself  in  two  or  three  instances  used  a  linen  thread  with  ex- 
cellent results. 

Guillaume  de  Salicet  advises  to  secure  with  a  silk  thread,  at  the 
same  moment,  the  teeth  belonging  to  the  two  fragments,  and  the  cor- 
responding teeth  of  the  upper  jaw;'  while  the  dentist  Lemaire,  being 
applied  to  by  Dupuytren  to  secure  in  place  the  ununited  fragments  of 
a  broken  jaw,  fastened  the  two  left  canine  teeth  to  each  other  by  a 
wire  of  platinum,  as  had  been  already  suggested  by  Guillaume  de 
Salicet;  to  these  he  added  two  other  modes  of  ligature  which  were 
altogether  original.  One  wire,  made  fast  to  the  last  molar  upon  one 
side,  traversed  the  mouth  and  was  secured  to  one  of  the  bicuspids 
upon  the  opposite  side  ;  the  other  was  stretched  from  the  first  inferior 
bicuspid  on  the  right  to  the  first  superior  bicuspid  on  the  left.  A 
cure  was  accomplished  at  the  end  of  two  months,  but  one  of  the  wires 
had  nearly  bisected  the  tongue;  and  as  it  had  gradually  become  im- 
bedded, the  flesh  had  closed  over  it  until  it  rested  like  a  seton  through 
the  middle  of  the  tongue.^ 

None  of  these  various  methods,  however,  will  in  general  be  found 
to  possess  much  value;  for  besides  that  they  are  all  of  them,  in  a 
large  majority  of  cases,  wholly  unnecessary,  and  in  other  cases,  owing 
to  the  absence  of  the  teeth,  or  to  their  loosened  or  decayed  condition, 
or  to  the  closeness  with  which  they  are  set  against  each  other,  abso- 
lutely impossible,  it  must  be  seen,  also,  that  they  will  generally  prove 
feeble  and  inefficient.  The  wires  act  only  upon  the  upper  extremity 
of  the  line  of  fracture,  leaving  its  lower  portions  liable  to  be  disturbed 
by  trivial  causes;  they  tend  gradually  to  loosen  even  the  firm  teeth 
which  they  embrace,  and  not  unfrequently,  after  having  been  made 
fast  with  much  labor,  they  soon  become  disarranged  or  break.  They 
require,  therefore,  almost  always  the  additional  protection  afforded  by 
bandages,  interdental  splints,  &c.  Alone  they  are  usually  insufficient, 
and  if  properly  constructed  bandages,  slings,  interdental  splints,  &c., 
are  employed,  they  are  not  needed.  Sometimes,  moreover,  they  are 
actually  mischievous,  as  when  they  loosen  a  sound  tooth  or  press  upon 
and  inflame  the  gums.  A.  Berard  passed  a  silver  wire  twice  around 
the  necks  of  two  adjoining  teeth  on  the  opposite  sides  of  a  fracture. 
It  retained  the  fragments  perfectly  in  apposition  during  several  days  ; 
but  soon  the  gums  swelled  and  became  painful ;  the  teeth  loosened, 
and  it  was  found  necessary  to  remove  the  wire.  Chassaignac  sought 
to  avoid  these  evils  by  placing  the  wire  upon  the  middle  of  the  crown, 
free  from  the  gum^s,  and  by  including  four  teeth  instead  of  two.  A 
waxed  linen  thread  was  made  fast  in  this  manner,  in  a  case  of  simple 
fracture,  on  the  seventh  day.  On  the  following  morning  the  thread 
was  found  broken.  He  applied  then  a  silk  ligature  in  the  same  man- 
ner. On  about  the  third  day  this  also  was  disarranged  ;  the  ligatures 
were  now  discontinued  until  the  eighteenth  day,  when  he  renewed 
the  experiment  with  a  piece  of  gold  wire.  Fourteen  days  after  this 
the  ligature  remained  firm,  but  the  gums  were  red  and  bleeding.     The 

'  Malgaigne,  op.  cit.,  p.  392. 

*  Journ.  Univer.  des  Sci.  Med.,  torn.  xix.  p.  77. 


122  FRACTUEES    OF    THE    LOWER    JAW. 

patient  not  having  again  returned  to  Chassaignac,  the  result  is  not 
known.^ 

As  to  the  method  suggested  by  Guillaume  de  Salicet,  it  presents  no 
advantages  to  compensate  for  its  inconveniences ;  while  that  actually 
practised  by  the  dentist  Lemaire,  successful  indeed,  threatened  to  sub- 
stitute a  loss  of  the  tongue  for  an  ununited  fracture  of  the  jaw. 

Splints  have  been  employed  in  various  ways.  First,  simple  inter- 
dental splints,  laid  along  the  crowns  of  the  teeth,  and  only  sufficiently 
grooved  to  be  easily  retained  in  place ;  second,  clasps,  which  are  ap- 
plied over  the  crowns  and  sides  of  the  teeth,  operating  chiefly  by  their 
lateral  pressure,  or  made  fast  by  screws ;  third,  splints  applied  to  the 
outer  and  inferior  margin  of  the  jaw ;  fourth,  interdental  splints  com- 
bined with  outside  splints. 

Interdental  splints  have  been  recommended  by  many  surgeons  from 
an  early  day,  and  they  continue  to  be  employed  occasionally  up  to 
this  moment. 

Boyer  advises  the  use  of  cork  splints,  placed  one  on  each  side  be- 
tween the  upper  and  lower  jaws,  in  a  few  exceptional  cases.  Miller 
recommends  the  same  in  all  cases,  the  "two  edges  of  cork  sloping 
gently  backwards,  with  their  upper  and  under  surfaces  grooved  for 
the  reception  of  the  upper  and  lower  teeth."  Fergusson  also  has 
usually  adopted  the  same  practice.  Muys  and  Bertrandi  employed 
ivory  wedges.^ 

On  the  other  hand,  they  are  rejected  entirely  by  Syme,  Chelius,  Skey, 
Brichsen,  and  Gibson. 

The  objections  which  have  been  stated  to  their  use  are :  that  they 
are  unsteady  and  become  easily  loosened  and  disarranged ;  that  they 
occasionally  press  painfully  upon  the  inside  of  the  cheeks  ;  that  they 
accumulate  about  themselves  an  offensive  sordes;  and  finally,  that  they 
are  unnecessary,  since  experience  has  proven,  says  Gibson,  that  "  there 
is  always  sufficient  space  between  the  teeth  to  enable  the  patient  to 
imbibe  broth  or  any  other  thin  fluid  placed  between  the  teeth." 

It  is  not  strictly  true,  however,  that  in  all  cases  there  will  be  found 
sufficient  space  between  the  teeth,  when  the  mouth  is  closed,  for  the 
imbibition  of  nutrient  fluids.  I  have  myself  seen  exceptions,  and  in 
such  a  case  the  patient,  if  the  mouth  were  closed  in  the  usual  way, 
would  have  to  be  fed  through  a  tube  conveyed  along  the  nostrils  into 
the  stomach,  as  suggested  by  both  Samuel  and  Bransby  Cooper  in 
certain  bad  compound  fractures,  or  through  an  opening  made  by  the 
extraction  of  one  of  the  front  teeth  ;  neither  of  which  methods  ought 
to  be  preferred  to  the  interdental  splints ;  but  then  the  separation  of 
the  front  teeth  for  the  purpose  of  receiving  food,  is  by  no  means  the 
only  object  to  be  gained  by  their  use,  nor  indeed  the  principal  object. 
Their  great  purpose  is  to  act  as  splints  whenever  the  absence  of  teeth 
either  in  the  upper  or  lower  jaw  readers  the  two  corresponding  arcades 
unequal  and  irregular,  and  prevents  our  making  use  of  the  upper  as 
a  kind  of  internal  splint  for  the  lower  jaw. 

'  Lond.  Med.  and  Phys.  Journ.,  Nov.  1822,  p.  401. 
2  Lond.  Med.-Chir.  Rev.,  vol.  xx.  p.  470. 


FEACTURES    OF    THE    LOWER    JAW.  123 

It  is  with  a  view  to  the  accomplishment  of  this  important  end  that 
they  are  often  valuable,  and  ought  sometimes  to  be  considered  as  in- 
dispensable. I  believe,  also,  that  many  of  the  inconveniences  which 
have  been  found  to  attend  the  use  of  cork  or  wood,  are  obviated  by 
the  substitution  of  gutta  percha  in  the  manner  which  I  recommended 
to  the  profession  in  1849,^  and  also  again  in  my  report  to  the  Ameri- 
can Medical  Association,  made  in  the  year  1855. 

The  mode  of  preparing  gutta  percha,  and  of  adapting  it  between 
the  teeth,  is  as  follows:  Dip  a  couple  of  pieces  of  the  gum,  of  a 
proper  size,  into  hot  water,  and  when  they  are  softened,  mould  them 
into  wedge-shaped  blocks,  and  carry  them  to  their  appropriate  places 
between  the  back  teeth  on  each  side  of  the  mouth  ;  taking  care,  of 
course,  that  on  the  fractured  side  the  splint  extends  sufficiently  far 
forward  to  traverse  thoroughly  the  line  of  fracture.  Now  press  up 
each  horizontal  ramus  of  the  jaw  until  the  mouth  is  sufficiently  closed, 
and  the  line  of  the  inferior  margin  is  straight;  in  this  position  retain 
the  fragments  a  few  minutes,  until  the  gum  has  well  hardened.  Mean- 
time it  will  be  practicable,  generally,  to  introduce  the  fingers  into  the 
mouth,  and  to  press  the  gutta  percha  laterally  on  each  side  towards 
the  teeth,  and  thus  to  make  its  position  more  secure.  When  it  is 
hardened,  remove  the  splints,  for  the  purpose  of  determining  more 
precisely  that  they  are  properly  shaped  and  fitted. 

It  is  scarcely  necessary  to  say  that  in  carrying  the  long  wedge- 
shaped  block  into  the  mouth,  the  apex  of  the  wedge  is  to  be  intro- 
duced first. 

The  superiority  of  this  splint  is  now  at  once  perceived.  If  properly 
made,  it  is  smooth  upon  its  surface,  and  not,  therefore,  so  liable  to 
irritate  the  mouth  as  wood  or  cork,  and  it  is  so  moulded  to  the  teeth 
that  it  will  never  become  displaced.  It  possesses  this  advantage,  also, 
that  in  case  more  or  less  of  the  teeth  are  gone  in  either  the  upper  or 
lower  jaw,  it  fills  up  the  vacancies,  and  renders  the  support  uniform 
and  steady. 

The  "  clasp,"  applied  over  the  crowns  and  sides  of  the  teeth,  is  not 
intended  to  act  as  an  interdental  splint;  but  by  its  lateral  pressure  it 
is  expected  to  hold  the  fragments  in  apposition  upon  nearly  the  same 
principle  with  the  ligature. 

Miitter,  of  Philadelphia,  and  N.  E.  Smith,  of  Baltimore,  employ  for 
this  purpose  a  plate  of  silver,  folded  snugly  over  the  tops  and  sides 
of  two  or  more  teeth  adjacent  to  the  fracture. 

Nicole,  of  Nuremburg,  employed  for  the  same  purpose  a  couple  of 
steel  plates  fitted  accurately  along  the  anterior  and  posterior  dental 
curvatures,  secured  in  place  by  a  steel  clasp,  the  clasp  being  furnished 
with  a  thumb-screw,  in  order  the  more  effectually  to  accomplish  the 
lateral  pressure. 

Malgaigne  has  extended  the  idea  of  Nicole,  by  substituting  for  the 
two  steel  plates  a  single  plate  composed  of  flexible  and  ductile  iron, 
which  is  fitted  accurately  to  all  the  irregularities  of  the  posterior 
dental  arch.     From  the  two  extremities  of  this  plate,  and  from  two 

•  Buffalo  Med.  and  Surg.  Journ.,  vol.  v.  p.  144,  Aug.  1849. 


124  FRACTURES    OF    THE    LOWER    JAW. 

Other  intermediate  points,  four  small  steel  shafts  arise  perpendicularly, 
cross  the  crowns  of  the  teeth  at  right  angles,  and  then  fall  down  again 
perpendicularly  upon  the  anterior  dental  arcade.  Each  steel  shaft 
being  furnished  with  a  thumb-screw,  the  iron  plate  can  now  be  made  to 
bear°against  the  teeth  so  as  to  form  a  posterior  dental  splint.  The 
teeth  are  also  protected  in  front  against  the  direct  action  of  the  thumb- 
screw by  the  interposition  of  a  leaden  plate. 

J.  B.  Gunnino-,  Dentist,  of  New  York,  has  substituted  for  all  these 
materials  vulcanized  India-rubber,  which  he  employs  both  as  a  clasp 
and  as  an  interdental  splint;  and,  according  to  Dr.  Covey ,^  the  same 
material  has  been  used  with  excellent  results  by  J.  B.  Bean,  Dentist, 
of  Atlanta,  Ga.     The  following  is  Dr.  Bean's  plan  of  procedure. 

An  impression  is  taken  in  wax  of  the  crowns  of  the  teeth  of  the 
uninjured  jaw,  and  of  each  fragment  separately  of  the  broken  jaw. 
When,  in  doing  this,  the  ordinary  "impression  cup"  used  by  dentists 
cannot  be  introduced,  one  composed  of  a  thin  metallic  plate,  which 
is  covered  with  wax  and  stiffened  by  a  rim  of  wire,  may  be  substituted. 
"From  these  impressions  are  made  casts  of  plaster  of  Paris,  very 
carefully  prepared,  so  as  to  produce  a  smooth,  hard  surface,  and  giving 
as  perfect  a  representation  of  the  teeth  as  possible.  These  plaster 
models  are  then  adjusted,  properly  antagonized  in  their  normal  posi- 
tion, and  placed  in  the  '  maxillary  articulator.' 

"  The  fragments  of  the  model  representing  the  broken  jaw  are  held 
in  their  proper  position  by  wax,  being  secured  thus  one  to  the  other, 
and  to  the  remaining  plate  of  the  articulator."  *  *  *  The  model  jaws 
are  now  opened  from  three  to  five  lines,  and  a  wax  model  of  a  splint  is 
built  up  between  the  molars,  covering  also  the  inner  and  outer  surfaces 
of  the  teeth.  A  connecting  band  of  wax  is  laid  from  one  side  to  the 
other  behind  the  upper  front  teeth,  leaving  thus  an  opening  in  front 
for  the  reception  of  the  food.  This  wax  and  plaster  model  now  com- 
posing one  piece,  is  then  removed  from  the  articulator,  and  placed  in 
a  dentist's  "  flask,"  and  a  complete  mould  of  the  model  is  again  formed 

from  plaster  laid   on  in  sections 
Fig.  26.  in  a  manner  which  those  accus- 

tomed to  make  plaster  moulds 
will  readily  understand.  The 
plaster  having  fairly  set,  the  flask 
and  mould  are  opened,  the  wax 
carefully  removed,  and  the  spaces 
thus  left  in  the  mould  at  once 
filled  with  the  rubber  rendered 
soft  by  heat.  The  mould  is  again 
closed,  replaced  in  the  flask,  and 
Maxillary  Articulator.  by  hcat  the  Tubbcr  is  thoroughly 

1, 1.  Upper  and  lower  plates.  vulcauizcd.     The   flask   is   again 

2,  2.  Adjustable  rods.  t       i  i  i  j 

3,  3.  Adjustable  hinge.  Opened,  the  plaster  removed,  and 

an  interdental  splint  of  rubber 
remains,  which  is  fitted  accurately  to  all  the  surfaces  of  the  teeth  both 
above  and  below. 

'  Bean,  Riclimoud  Med.  Journ.,  Feb.  1866. 


FEACTURES    OF    THE    LOWER    JAW. 


125 


Fio;.  27. 


Beans'  apparatus  for  broken  jaw,  applied. 


The  splint  is  now  placed  in  the  mouth,  adjusted  to  the  teeth,  and 
the  lower  jaw  secured  in  position  by  the  apparatus  represented  in  the 
accompanying  wood-cut. 

Dr.  Covey  says,  that  during  the  late  war  Dr.  Bean  was  placed  in 
charge  of  a  hospital  at  Macon,  Geor- 
gia, devoted  exclusively  to  the  re- 
ception of  this  class  of  injuries,  and 
that  over  forty  cases  were  treated, 
and  with  eminent  success. 

My  own  judgment  of  this  appara- 
tus is,  that  so  far  as  the  substitution 
of  vulcanized  rubber  forgutta  percha 
is  concerned,  it  is  wholly  unnecessary 
in  the  great  majority  of  simple  frac- 
tures of  the  jaw.  Gutta  percha  is 
applied  with  great  facility,  and  with 
equal  accuracy  to  all  the  dental  sur- 
faces, and  it  speedily  hardens  suffi- 
ciently for  all  practical  purposes. 

In  gunshot  fractures,  however,  and 
in  certain  other  badly  comminuted 
fractures,  I  can  well  understand  how 
the  surgeon  may  advantageously  avail 
himself  of  vulcanized  rubber,  which,  being  somewhat  harder,  may  be 
made  to  grasp  the  teeth  attached  to  the  several  fragments  more 
firmly ;  and  indeed  may,  in  a  few  cases,  allow  of  the  teeth  being  made 
fast  to  the  splint  by  screws. 

It  will  be  observed  that  these  are  the  cases  which  Dr.  Bean  has  had 
chiefly  under  treatment. 

An  examination  of  the  cases  reported  by  Dr.  Covey  will  also  show 
that  the  apparatus  was  never  applied  earlier  than  the  tenth  day,  even 
when  the  patients  were  under  the  charge  of  Dr.  Bean  from  the  first, 
and  that  in  most  cases  the  application  of  the  apparatus  was  delayed 
to  a  much  later  period.  Indeed,  it  is  apparent  that  there  may  be  the 
same  reasons  for  occasional  delay  in  the  application  of  vulcanized  rub- 
ber as  in  the  application  of  gutta  percha,  or  any  other  mode  of  sup- 
port and  dressing. 

In  reference  to  the  head  apparatus,  or  sling,  as  used  by  Dr.  Bean, 
we  have  only  a  single  remark  to  make.  It  is  a  modification  of  the 
apparatus  employed  for  many  years  by  myself — the  modification  con- 
sisting in  the  use  of  a  horizontal  piece  of  wood  supporting  a  cup 
which  is  placed  under  the  chin,  the  purpose  of  which  is  to  prevent 
the  lateral  pressure  usually  made  by  the  maxillary  bands.  The 
necessity  of  this  modification  has  long  been  recognized  by  myself  and 
others  in  certain  fractures;  and  it  is  especially  important  in  all  com- 
minuted and  gunshot  fractures.  To  the  attainment  of  this  purpose, 
namely,  the  prevention  of  lateral  pressure,  I  have  employed  usually  a 
firm  gutta-percha  splint  under  the  chin,  to  the  projecting  lateral  ex- 
tremities of  which  the  maxillary  bands  have  been  attached  ;  and  I 
think  it  much  better  than  Dr.  "Bean's  piece  of  wood.     In  a  great 


126  FRACTUEES    OF    THE    LOWER    JAW. 

majority  of  cases,  however,  occurring  in  civil  practice,  that  is  to  say, 
in  most  simple  fractures,  this  submental  splint  is  unnecessary,  since 
the  lateral  pressure  is  harmless,  especially  when  the  interdental  splints 
of  gutta  percha  or  of  vulcanized  rubber  are  employed. 

In  short,  while  I  am  prepared  to  admit  that  Dr.  Bean  has  by  his 
a2:>pareil,  and  by  the  application  of  great  mechanical  skill,  talent,  and 
industry,  treated  successfully  many  cases  which  by  other  appliances 
and  in  other  hands  might  have  resulted  most  unfortunately,  yet  it  is 
plain  that  his  method  will  find  its  field  of  usefulness  in  civil  practice 
limited  to  exceptional  cases. 

Dr.  J.  S.  Prout,  of  Brooklyn,  New  York,  has  suggested  to  me  a  very 
ingenious  mode  of  employing  the  interdental  splint  and  wire  ligature 
conjointly,  and  which  method,  at  my  request,  he  adopted  recently  in 
a  case  under  my  care  at  Bellevue  Hospital.  A  plate  of  gutta  percha 
was  placed  upon  the  top  of  the  teeth  across  the  line  of  fracture,  and 
this  was  secured  in  position  by  silver  wire,  which  had  been  made  to 
grasp  firmly  the  crowns  of  the  adjacent  teeth  and  was  then  brought 
over  the  horizontal  gutta-percha  plate.  In  this  case  it  accomplished 
all  that  was  desired. 

External  splints,  applied  along  the  base  or  outside  of  the  jaw,  were 
first  recommended  by  Pare,  who  used  for  this  purpose  leather;  and 
they  have  been  employed  in  some  form,  occasionally,  by  most  surgeons. 
Generally  they  have  been  composed  of  flexible  materials,  such  as 
wetted  pasteboard,  first  recommended  by  Heister,  felt,  linen  saturated 
with  the  whites  of  eggs,  paste,  dextrine,  or  starch ;  plaster  of  Paris  has 
also  been  used  ;  and  they  have  been  retained  in  place  by  either  band- 
ages or  the  sling.  As  before  stated,  I  have  myself  used  for  this  purpose, 
gutta  percha,  but  I  shall  speak  of  it  as  one  form  of  the  sling  dressing. 

Undoubtedly  useful,  and  even  necessary  in  some  cases,  especially 
where  there  exists  a  great  tendency  to  a  vertical  displacement,  they 
will  be  found,  also,  in  many  cases,  to  render  no  essential  service,  and 
may  properly  enough  be  dispensed  with. 

Whatever  objections  hold  to  the  use  of  metallic  clasps,  must  apply 
in  some  degree  to  the  use  of  those  forms  of  apparatus  in  which  it  is 
attempted  to  secure  the  fragments  by  means  of  a  combination  of  these 
clasps  with  outside  splints,  and  in  which  it  is  proposed  to  dispense  with 
all  bandages  or  slings,  the  mouth  being  permitted  to  open  and  close 
freely  during  the  whole  treatment.  Motion  of  the  jaw  cannot  be  per- 
mitted in  any  case  where  the  fracture  is  far  back,  since  it  is  then  im- 
possible to  grasp  the  posterior  fragment  between  the  two  parallel 
splints.  Nothing  but  complete  immobility  of  the  jaw  will  now  insure 
immobility  to  the  fracture.  Some  of  these  forms  of  apparatus  are 
liable  to  additional  objections,  which  will  be  readily  suggested  by  an 
explanation  of  their  mode  of  construction. 

Chopart  and  Desault  originated  this  idea  as  early  as  1780,  for  frac- 
tures occurring  upon  both  sides  ;  in  which  cases  they  advised  "band- 
ages composed  of  crotchets  of  iron  or  of  steel,  placed  over  the  teeth, 
upon  the  aveolar  margin,  covered  with  cork  or  with  plates  of  lead, 
and  fastened  by  thumb-screws  to  a  plate  of  sheet-iron,  or  to  some 
other  material  under  the  jaw." 


FRACTURES    OF    THE    LOWER    JAW.  127 

The  apparatus  invented  by  Rutenick,  a  German  surgeon,  in  1799, 
and  improved  by  Kluge,  is  thus  described  by  Dr.  Chester:  "It  con- 
sists, 1st,  of  small  silver  grooves,  varying  in  size  according  as  they 
are  to  be  placed  on  the  incisors  or  molars,  and  long  enough  to  extend 
over  the  crowns  of  four  teeth ;  2d,  of  a  small  piece  of  board,  adapted 
to  the  lower  surface  of  the  jaw,  and  in  shape  resembling  a  horseshoe, 
having  at  its  two  horns,  two  holes  on  each  side ;  3d,  of  steel  hooks  of 
various  sizes,  each  having  at  one  extremity  an  arch  for  the  reception 
of  the  lower  lip,  and  another  smaller  for  securing  it  over  the  silver 
channels  on  the  teeth,  and  at  the  other  end  a  screw  to  pass  through  the 
horseshoe  splint,  and  to  be  secured  to  it  by  a  nut  and  a  horizontal 
branch  at  its  lower  surface ;  4th,  of  a  cap  or  silk  nightcap  to  remain 
on  the  head ;  and  5th,  of  a  compress  corresponding  in  shape  and  size 
with  the  splint.  The  net  or  cap  having  been  placed  on  the  head,  and 
the  two  straps  fastened  to  it  on  each  side,  one  immediately  in  front  of 
the  ear  and  the  other  about  three  inches  farther  back,  which  are  to 
retain  the  splint  in  its  position  by  passing  through  the  two  holes  in 
each  horn,  a  silver  channel  is  placed  on  the  four  teeth  nearest  to  the 
fracture ;  on  this  the  small  arch  of  the  hook  is  placed,  and  the  screw 
end  having  been  passed  through  a  hole  in  the  splint,  is  screwed  firmly 
to  it  by  the  nut,  after  a  compress  has  been  placed  between  the  splint 
and  the  integuments  below  the  jaw. 

"  If  there  is  a  double  fracture,  two  channels  and  two  hooks  must  of 
course  be  used.'" 

Bush  invented  a  similar  apparatus  in  1822,^  and  Houzelot  in  1826 ; 
since  which  the  apparatus  has  been  variously  modified  by  Jousset, 
Lonsdale,  Malgaigne,  and  perhaps  others. 

Lonsdale  says  he  has  employed  his  instrument  in  numerous  cases, 
and  with  complete  success.^  Rutenick  succeeded  with  his  apparatus 
in  a  case  where  the  displacement  persisted  in  spite  of  all  other  means.* 
Jousset  was  also  successful  in  two  cases.^  Wales,  Asst.  Surg.  U.  S. 
Navy,  succeeded  with  an  instrument  of  his  own  invention," 

But  others  have  not  been  equally  fortunate;  or  if  they  have  suc- 
ceeded in  holding  the  fragments  in  apposition,  and  in  securing  a  bony 
union,  other  serious  accidents  have  followed. 

In  the  first  case  mentioned  by  Houzelot,  the  instrument  was  kept 
on  thirteen  days,  after  which  an  attack  of  epilepsy  deranged  every- 
thing, and  the  patient  was  transferred  to  Bicetre.  The  second  patient 
complained  immediately  of  an  intense  pain  under  the  chin,  and  a  pro- 
fuse salivation  followed.  These  symptoms  were  subdued  by  the  sixth 
day,  but,  for  some  reason,  the  apparatus  was  finally  removed  on  the 
tenth  day.  The  fragments  hereafter  showed  no  tendency  to  derange- 
ment. Seven  days  after  its  removal,  an  abscess,  which  had  formed 
under  the  chin,  was  opened.     In  the  third  case  the  apparatus  was  left 

'  London  Med.-Chir.  Rev.,  vol.  xx.  p.  471,  from  Monthly  Archives  of  the  Medi- 
cal Sciences,  1834. 
2  Malgaigne,  op.  cit.,  p.  395. 

»  Lonsdale,  Practical  Treatise  on  Fractures ;  London,  1838,  p.  234. 
<  Malgaigne,  op.  cit.,  p.  396.  s  ibid.,  p.  396. 

6  Wales,  Am.  Journ.  Med.  Sci.,  Oct.  1860. 


128  FRACTURES    OF    THE    LOWER    JAW. 

in  place  thirty  days,  and  an  abscess  formed  also  under  the  chin 
Neucourt  applied  it  in  a  double  fracture  where  the  central  fragment 
was  much  displaced.  The  apposition  was  well  preserved,  but  he  was 
obliged  to  remove  it  on  the  seventeenth  day  on  account  of  a  phlegmon 
which  was  forming  under  the  chin.  The  patient  to  whom  Bush  ap- 
plied his  apparatus,  would  wear  it  but  a  few  days,  Malgaigne  had 
the  same  experience  with  Bush's  apparatus. , 

In  addition  to  the  pain  and  inflammation,  followed  by  submaxil- 
lary abscesses,  which  have  been  such  frequent  results  of  its  use, 
Malgaigne  has  noticed  that  it  is  exceedingly  inclined  to  slide  forwards 
and  become  displaced. 

In  short,  notwithstanding  the  unqualified  testimony  of  Lonsdale  in 
favor  of  this  method  of  treatment,  especially  in  fractures  at  the  sym- 
physis, and  in  fractures  through  any  portion  of  the  shaft  anterior  to 
the  masseter  muscle,  it  is,  in  my  judgment,  sufficiently  plain  that  it  is 
applicable  to  only  a  very  limited  number  of  cases;  but  if  I  were  to 
recommend  any  form  of  apparatus  constructed  with  a  view  of  per- 
mitting mobility  of  the  jaws  during  the  process  of  union,  it  would 
be  that  invented  by  Norman  Kingsley,  Dentist,  of  this  city,  and  which 
I  have  seen  used  with  excellent  results  at  Bellevue  Hospital. 

Impressions  in  plaster  are  first  taken  of  both  upper  and  lower  jaws. 
Models  made  from  these  impressions  will  represent  the  lower  jaw 
broken  and  the  fragments  displaced.  The  model  of  the  lower  jaw  is 
then  separated  at  the  point  representing  the  fracture,  and  the  frag- 
ments adjusted  to  the  model  of  the  upper  jaw.  In  most  cases  the 
position  which  these  fragments  assume  when  thus  placed,  determines 
accurately  the  original  form  and  position  of  the  lower  jaw.  Upon  the 
plaster  model  of  the  lower  jaw,  obtained  and  rectified  in  this  way,  a 
splint  or  clasp  of  vulcanite  rubber  is  then  made,  embracing  the  arms, 
which  are  made  of  steel  wire,  one-sixteenth  of  an  inch  in  diameter. 
Thearms  must  curve  upwards  a  little  as  they  emerge  from  the  mouth, 
to  avoid  pressure  upon  the  lips,  and  then  curve  backwards,  termi- 
nating near  the  angles  of  the  jaw. 

When  the  apparatus  is  applied,  the  teeth  must  be  pushed  into  the 
sockets  of  the  splint  with  some  force.  The  dressing  is  now  com- 
pleted by  a  sling  made  of  strong  muslin,  extending  beneath  the  chin 
from  one  arm  to  the  other. 

George  L.  Fitch,  Dentist,  California,  believes  that  "dental  gutta 
percha"  may  be  made  to  answer  the  same  purpose  as  vulcanite  rub- 
ber, in  the  construction  of  this  and  other  similar  splints.^  In  this 
opinion,  however,  Dr.  Kingsley  does  not  concur. 

The  treatment  of  fractures  of  the  inferior  maxilla  by  a  single-headed 
bandage  or  roller,  numbers  among  its  distinguished  advocates  the 
names  of  Gibson  and  Barton ;  indeed,  I  think  the  practice  is  at  the 
present  time  peculiar  to  a  few  American  surgeons.  Gibson  gives  the 
following  directions  for  applying  his  roller:  ''A  cotton  or  linen  com- 
press, of  moderate  thickness,  reaching  from  the  angle  of  the  jaw 
nearly  to  the  chin,  is  placed  beneath,  and  held  by  an  assistant,  while 

'  Fitch,  New  York  Med.  Gazette,  1869. 


FRACTURES    OF    THE    LOWER    JAW. 


129 


Gibson's  bandage  for  a  fractured  jaw. 


the  surgeon  takes  a  roller,  four  or  five  Fig.  28. 

yards  long,  an  inch  and  a  half  wide,  and 
passes  it  by  several  successive  turns 
under  the  jaw,  up  along  the  sides  of  the 
face,  and  over  the  head ;  now  changing 
the  course  of  the  bandage,  he  causes  it 
to  pass  off  at  a  right  angle  from  the 
perpendicular  cast,  and  to  encircle  the 
temple,  occiput,  and  forehead,  horizon- 
tally, by  several  turns  ;  finally,  to  render 
the  whole  more  secure,  several  addi- 
tional horizontal  turns  are  made  around 
the  back  of  the  neck,  under  the  ear, 
along  the  base  of  the  jaw,  under  the 
point  of  the  chin.  To  prevent  the  roller 
from  slipping  or  changing  its  position, 
a  short  piece  may  be  secured  by  a  pin  to  the  horizontal  turn  that  en- 
circles the  forehead,  and  passed  backwards  along  the  centre  of  the 
head  as  far  as  the  neck,  where  it  must  be  tacked  to  the  lower  hori- 
zontal turn — taking  care  to  fix  one  or  more  pins  at  every  point  at 
which  the  roller  has  crossed." 

Barton  employs,  also,  a  compress,  and  a  roller  five  yards  long ;  the 
application  of  which  is  thus  described  by  Sargent:  Place  the  initial 
extremity  of  the  roller  upon  the  occiput,  just 
below  its  protuberance,  and  conduct  the 
cylinder  obliquely  over  the  centre  of  the  left 
parietal  bone  to  the  top  of  the  head ;  thence 
descend  across  the  right  temple  and  the  zy- 
gomatic arch,  and  pass  beneath  the  chin  to 
the  left  side  of  the  face ;  mount  over  the  left 
zygoma  and  temple  to  the  summit  of  the 
cranium,  and  regain  the  starting  point  at  the 
occiput  by  traversing  obliquely  the  right 
parietal  bone  ;  next  wind  around  the  base  of 
the  lower  jaw  on  the  left  side  to  the  chin, 
and  thence  return  to  the  occiput  along  the 
right  side  of  the  maxilla ;  repeat  the  same 
course,  step  by  step,  until  the  roller  is  spent, 
and  then  confine  its  terminal  end. 

These  bandages  possess  the  advantages  of  being  easily  obtained, 
of  simplicity  and  facility  of  application,  and,  we  may  add,  if  considered 
in  relation  to  the  majority  of  simple  fractures,  of  complete  adaptation 
to  the  ends  proposed.  The  only  objections  to  their  use  which  I  have 
ever  noticed,  are  occasional  disarrangements,  and  the  tendency,  as  in 
all  other  continuous  rollers,  to  draw  the  fragments  to  one  side  or  the 
other,  according  as  the  successive  turns  of  the  bandage  are  carried 
to  the  right  or  left.  There  is  one  other  objection,  having  reference 
to  the  occasional  inadequacy  of  this  dressing  to  prevent  an  overlap- 
ping of  the  fragments;  to  which  objection  also  the  sling,  as  usually 


Barton's  bandage  for  a 
fractured  jaw. 


130 


FRACTUEES    OF    THE    LOWER    JAW. 


Fig.  30. 


Foui'-tailed  bandage  or  sling,  for  the  lower 
jaw. 


constructed,  is  equally  obnoxious,  and  of  whicli  I  shall  speak  pre- 
sently. 

Finally,  it  is  to  the  sling,  in  some  of  its  various  forms,  with  or  with- 
out the  interdental  splint,  that  surgeons  have  generally  given  the  prefer- 
ence.    The  sling  is  known,  also,  by 
the  name  of  the  four-headed  or  the 
four-tailed  roller  or  bandage. 

B,  Bell,  Boyer,  Skey,  S.  Cooper, 
B.  Cooper,  Syme,  Fergusson,  Mayor, 
Lizars,  and  Chelius  employ  the  sling, 
usually ;  and  the  favorite  mode  is  to 
use  for  this  purpose  a  piece  of  muslin 
cloth  about  one  yard  long  and  four 
inches  wide,  torn  down  from  its  two 
extremities  to  within  about  three  or 
four  inches  of  the  centre.  Others 
have  used  leather,  gutta  percha,  ad- 
hesive straps,  gum-elastic,  etc. 

Where  the  muslin  is  used,  it  is 
quite  customary  to  lay  against  the 
skin  a  piece  of  pasteboard,  wetted, 
and  moulded  to  the  chin,  or  simply 
a  soft  compress ;  and  some  choose  to 
open  the  centre  of  the  bandage  suffi- 
ciently to  receive  the  chin.  The  mid- 
dle of  this  bandage  being  laid  upon  the  chin,  the  two  ends  corre- 
sponding to  the  upper  margin  of  the  roller  are  now  carried  across  the 
front  of  the  chin,  behind  the  nape  of  the  neck,  and  made  fast ;  while 
the  two  lower  heads  are  brought  directly  upwards  from  under  the 
sides  of  the  chin,  along  the  sides  of  the  face,  in  front  of  the  ears, 
and  made  fast  upon  the  top  of  the  head.  The  dressing  is  completed 
by  a  short  counter-band  extending  across  the  top  of  the  head  from 
one  bandage  to  the  other ;  or  the  several  bands  may  be  made  fast  to 
a  nightcap,  in  which  case  the  counter-band  will  be  unnecessary. 

It  only  remains  for  me  to  describe  my  own  method  of  dressing  these 
fractures  with  the  sling. 

Having  frequently  noticed  the  tendency  of  the  sling,  as  ordinarily 
constructed,  and  of  Gibson's  roller,  to  carry  the  anterior  fragment 
backwards,  especially  in  double  fracture  where  the  body  of  the  bone 
is  broken  upon  both  sides,  I  devised,  some  years  since,  an  apparatus 
intended  to  obviate  this  objection,  and  which  I  have  used  now  many 
times  with  entire  satisfaction. 

It  is  composed  of  a  firm  leather  strap,  called  maxillary,  which, 
passing  perpendicularly  upwards  from  under  the  chin,  is  made  to 
buckle  upon  the  top  of  the  head,  at  a  point  near  the  situation  of  the 
anterior  fontanelle.  This  strap  is  supported  by  two  counter-straps, 
made  of  strong  linen  webbing,  called,  respectively,  the  occipito-frontal 
and  the  vertical.  The  occipito-frontal  is  looped  upon  the  maxillary 
at  a  point  a  little  above  the  ears,  and  may  be  elevated  or  depressed 
at  pleasure.     The  occipital  portion  of  the  strap  is  then  carried  back- 


FEACTURES    OF    THE    LOWER    JAW. 


131 


The  author's  apparatus. 


wards  and  buckled  under  the  occiput,  while  the  frontal  portion  is 
buckled  across  the  forehead.  The  vertical  strap  unites  the  occipital 
to  the  maxillary  across  the  top  of  the  head,  and  prevents  the  upper 
part  of  the  latter  from  becoming  displaced  forwards.  At  each  point 
where  a  buckle  is  used,  a  pad  must 
be  placed  between  the  strap  and  the 
head. 

The  maxillary  strap  is  narrow 
under  the  chin  to  avoid  pressure 
upon  the  front  of  the  neck,  but  im- 
mediately becomes  wider  so  as  to 
cover  the  sides  of  the  inferior  maxilla 
and  face,  after  which  it  gradually  di- 
minishes to  accommodate  the  buckle 
upon  the  top  of  the  head.  The  an- 
terior margin  of  this  band,  at  the 
point  corresponding  to  the  symphy- 
sis menti,  and  for  about  two  inches 
on  each  side,  is  supplied  with  thread 
holes,  for  the  purpose  of  attaching 
a  piece  of  linen  which,  when  the  ap- 
paratus is  in  place,  shall  cross  in 
front  of  the  chin,  and  prevent  the 
maxillary  strap  from  sliding  back- 
wards against  the  front  of  the  neck. 

The  advantage  of  this  dressing  over  any  which  I  have  yet  seen, 
consists  in  its  capability  to  lift  the  anterior  fragment  almost  vertically, 
while  at  the  same  time  it  is  in  no  danger  of  falling  forwards  and  down- 
wards upon  the  forehead.  If,  as  in  the  case  of  most  other  dressings, 
the  occipital  stay  had  its  attachment  opposite  to  the  chin,  its  effect 
would  be  to  draw  the  central  fragment  backwards.  By  using  a  firm 
piece  of  leather,  as  a  maxillary  band,  and  attaching  the  occipital  stay 
above  the  ears,  this  difficulty  is  completely  obviated. 

Having  removed  such  teeth  as  are  much  loosened  at  the  point  of 
fracture,  and  replaced  those  which  are  loosened  at  other  points,  unless 
it  be  far  back  in  the  mouth,  and  adjusted  the  fragments  accurately, 
the  lower  jaw  is  to  be  closed  completely  upon  the  upper,  and  the 
apparatus  snugly  applied.  It  is  not  necessary  in  most  cases  to  buckle 
the  straps  with  great  firmness,  since  experience  has  shown  that  a 
sufficient  degree  of  immobility  is  usually  obtained  when  the  apparatus 
is  only  moderately  tight. 

If  the  integuments  are  bruised  and  tender,  a  compress  made  of  two 
or  more  thicknesses  of  patent  lint  should  be  placed  underneath  the 
chin,  between  it  and  the  leather. 

If  the  inability  to  introduce  nourishment  between  the  teeth  when 
the  mouth  is  closed,  or  the  irregularity  of  the  dental  arcade,  renders 
the  use  of  interdental  splints  necessary,  gutta  percha,  as  I  have 
already  explained,  ought,  in  general,  to  be  preferred  to  any  other 
material. 

The  patient  must  be  forbidden  to  talk  or  laugh,  and,  when  he  lies 


132  FRACTURES    OF    THE    LOWER    JAW. 

down,  his  head  should  rest  upon  its  back,  for  whatever  mode  of  dress- 
ing is  employed,  and  however  carefully  it  is  applied,  it  will  be  found 
that  a  slight  motion  and  displacement  will  occur  whenever  the  weight 
of  the  head  rests  upon  the  side  of  the  face. 

Occasionally,  indeed,  as  often  as  every  two  or  three  days,  the  appa- 
ratus may  be  loosened  or  removed,  only  taking  care  generally  not  to 
disturb  the  interdental  splints,  when  they  are  used,  and  to  support  the 
jaw  with  the  hand,  during  its  removal;  and,  at  the  same  time,  the  face 
may  be  sponged  off  with  warm  water  and  castile  soap.  It  should  not 
be  left  off'  entirely,  however,  in  less  than  three  or  four  weeks,  even 
where  the  fracture  is  most  simple,  nor  ought  the  patient  be  allowed  to 
eat  meat  in  less  than  four  or  five  weeks. 

To  cleanse  the  mouth  and  prevent  offensive  accumulations,  it  should 
be  washed  several  times  a  day  with  a  solution  of  tincture  of  myrrh, 
prepared  by  adding  one  drachm  to  about  four  ounces  of  water. 

The  same  apparatus,  and  without  any  essential  modification,  is  ap- 
plicable to  fractures  of  the  symphysis  and  of  the  angle  of  the  inferior 
maxilla,  as  well  as  to  fractures  of  the  body  of  the  bone. 

Instead  of  the  leather,  I  have  in  a  few  instances,  especially  of  com- 
pound fractures  where  it  became  necessary  to  allow  the  pus  to  dis- 
charge externally,  used  a  sling  or  a  splint  composed  of  gutta  percha, 
suspended  by  bands  carried  over  the  top  of  the  head.  The  piece 
from  which  this  splint  is  made  should  be  two  or  three  lines  in  thick- 
ness, covered  with  cloth,  and  padded  under  the  chin.  It  will  be  found 
convenient  to  cover  it  with  cloth  before  immersing  it  in  the  hot  water. 
The  water  should  be  nearly  at  a  boiling  temperature,  so  that  the  splint 
may  become  perfectly  pliable;  and  it  should  be  laid  upon  the  face 
and  allowed  to  mould  itself  while  the  patient  lies  upon  his  back. 

Having  thus  fitted  it  accurately  to  the  face,  it  may  be  removed  and 
openings  made  at  points  corresponding  with  the  wounds  upon  the 
skin,  before  it  is  reapplied. 

As  has  been  already  explained,  the  gutta  percha,  if  sufficiently  thick, 
and  if  the  lateral  wings  are  allowed  to  project  a  little  on  either  side, 
will  serve  effectually  to  protect  the  sides  of  the  face  against  pressure 
from  the  bandage ;  and  being  more  easily  moulded  to  the  base  and 
front  of  the  chin  than  any  other  material  which  has  yet  been  employed, 
must  have  the  preference.  The  necessity  for  its  use,  however,  is  only 
occasional. 

In^  fractures  of  either  condyle,  unaccompanied  with  displacement, 
the  simple  leather  or  muslin  sling  will  sometimes  accomplish  a  perfect 
and  speedy  cure,  as  the  two  cases  reported  by  Desault  will  sufficiently 
demonstrate.  But  if  the  fragments  have  become  separated,  the  re- 
placement is  difficult,  and  the  retention  uncertain. 

Eibes  was  the  first  to  suggest  and  to  practise  a  very  ingenious 
method  of  reduction  in  these  cases.  Having  seen  two  examples  which 
had  resulted  in  deformity  under  the  usual  treatment,  which  consisted 
in  simply  pressing  forwards  the  angle  of  the  jaw,  it  occurred  to  him 
that  while  the  upper  or  condyloidean  fragment  was  not  acted  upon  at 
the  same  moment  by  pressure  from  the  opposite  direction,  a  reduction 
must  be  impossible.     The  case  of  a  cannonier  whose  jaw  was  broken 


FRACTURES    OF    THE    HYOID    BONE.  133 

througli  the  neck  of  the  condyle  on  the  right  side,  and  through  its 
body  on  the  left,  afforded  him  an  opportunity  to  determine  the  prac- 
ticability of  a  method  of  which  he  had  as  yet  only  conceived  the  idea. 
Malgaigne  thus  describes  his  procedure:  "With  the  left  hand  seize  the 
anterior  portion  of  the  jaw,  for  the  purpose  of  drawing  it  horizontally 
forwards,  while  you  carry  the  index  finger  of  the  right  hand  to  the 
lateral  and  superior  .part  of  the  pharynx.  You  will  meet  at  first  the 
projection  formed  by  the  styloid  process,  but,  moving  your  finger  for- 
wards, you  will  find  soon  the  posterior  border  of  the  ramus  of  the  jaw ; 
and  following  this  border  from  below  upwards,  you  will  arrive  at  the 
inner  side  of  the  condyle,  which  you  will  push  outwards  in  such  a 
manner  as  to  engage  it  upon  the  other  fragment.  This  manoeuvre 
cannot  be  made  without  causing  nausea,  as  the  finger  always  does 
when  carried  into  the  posterior  part  of  the  pharynx  ;  but  this  is  a 
slight  inconvenience.  The  reduction  obtained,  bear  the  jaw  upwards 
and  backwards  in  order  to  press  and  fix  the  condyle  between  it  and 
the  glenoid  cavity,  then  fasten  it  in  place  with  a  sling."  The  frag- 
ments were  thus  easily  brought  into  apposition  in  the  case  reported 
by  Eibes,  and  the  patient  was  cured  without  any  deformity. 

In  addition  to  these  means,  the  angle  of  the  jaw  ought  to  be  pressed 
permanently  forwards  by  means  of  a  compress  placed  between  it  and 
the  mastoid  process,  and  held  in  place  by  a  suitable  bandage ;  or  we 
may  adopt  the  method  which  proved  so  successful  with  Fountain, 
namely,  wire  the  front  teeth  of  the  lower  jaw  to  the  front  teeth  of  the 
upper  in  such  a  manner  as  to  draw  the  chin  forwards,  and  thus  main- 
tain apposition. 

If  the  coronoid  process  be  alone  broken,  it  is  sufficient  to  close  the 
mouth  with  any  form  of  sling  or  bandage  which  may  be  most  con- 
venient. 


CHAPTER   XIII. 

FRACTURES  OF  THE  HYOID  BONE. 

M.  Orfila  has  reported  the  case  of  a  man,  aged  sixty-two  years,  who 
had  been  hanged,  and  whose  os  hyoides  was  broken  through  its  body 
on  its  right  side.^  M.  Cazauvieilh  has  also  seen  a  fracture  of  this 
bone  in  two  persons  who  had  been  hanged  :  in  one  of  which  the  frac- 
ture was  probably  in  the  body  of  the  bone,  and  in  the  other  through 
one  of  its  cornua.^ 

Lalesque  published  in  the  Journal  Hehdomadaire  for  March,  1833,  a 
case  which  occurred  in  a  marine,  sixty-seven  years  old,  "  who,  in  a 
quarrel,  had  his  throat  violently  clenched  by  the  hand  of  a  vigorous 
adversary.     At  the  moment  there  was  very  acute  pain,  and  the  sensa- 

'  Traite  de  Med.  legale,  troisieme  ed.,  torn.  ii.  p.  423. 
2  Cazauvieilh,  du  Suicide,  etc.,  p.  321. 


134  FRACTURES  OF  THE  HYOID  BONE. 

tion  of  a  solid  body  breaking.  The  pain  was  aggravated  by  every 
effort  to  speak,  to  swallow,  or  to  move  the  tongue,  and  when  this 
organ  was  pushed  backwards,  deglutition  was  impossible.  The  patient 
could  not  articulate  distinctly ;  and  he  was  unable  to  open  his  mouth 
without  exciting  a  great  deal  of  pain.  He  placed  his  hand  upon  the 
anterior  and  superior  part  of  his  neck  to  point  out  the  seat  of  the 
injury.  This  part  was  slightly  swollen,  and  presented  on  each  side 
small  ecchymoses;  one  above,  more  decided,  immediately  under  the  left 
angle  of  the  lower  jaw.  "  The  large  cornua  of  the  os  hyoides  was  very 
distinctly  to  the  right  side,"  and  it  could  be  felt  on  the  left  deeply  seated 
by  pressing  with  the  fingers  ;  in  following  it  in  front  toward  the  body 
of  the  bone,  a  very  sensible  inequality  near  the  point  of  junction  of 
these  two  parts  could  be  perceived.  By  putting  the  finger  within  the 
mouth,  the  same  projections  and  cavities  inverted  could  be  felt,  and 
even  the  points  of  the  bone  which  had  pierced  the  mucous  membrane, 
&c.,  were  evident.  Having  bled  the  patient,  and  placed  a  plug  between 
his  teeth  to  keep  the  mouth  open,  the  broken  branch  was  brought  by 
the  finger  back  to  the  surface  of  the  body  of  the  bone,  and  easily  re- 
duced. The  position  of  the  head  inclined  a  little  back ;  rest,  absolute 
silence,  diet,  and  some  saturnine  fomentations,  composed  the  after- 
treatment.  To  avoid  a  new  dislocation  by  the  efforts  of  swallowing, 
the  oesophagus  tube  of  Desault  was  introduced,  to  conduct  the  drinks 
and  liquid  aliments  into  the  stomach ;  this  sound  was  allowed  to  re- 
main until  the  twenty-fifth  day  ;  at  this  time  the  patient  could  swallow 
without  pain,  and  began  to  take  a  little  more  solid  nourishment,  and 
at  the  end  of  two  months  the  cure  was  complete.  By  placing  a  finger 
within  his  mouth,  a  slight  nodosity  could  be  felt  in  the  place  where, 
in  the  recent  fracture,  the  splintered  points  were  perceptible.' 

Dieffenbach  has  also  recorded  a  fracture  of  the  great  right  horn,  pro- 
duced in  the  same  manner,  by  grasping  the  throat  between  the  thumb 
and  fingers,  which  occurred  in  a  girl  only  nineteen  years  old.  Very 
slight  pressure  upon  the  side  of  the  bone  was  sufficient  to  move  the 
fragment  inwards,  and  to  produce  a  crepitus,  but  it  immediately 
resumed  its  place  when  the  pressure  was  removed.  There  being, 
therefore,  no  displacement,  the  cure  was  effected  in  a  short  time 
without  resort  to  any  remedies  except  tisans  and  antiphlogistics.  She 
was  not  even  forbidden  to  speak.^ 

Auberge  saw  a  similar  case,  in  a  person  fifty-five  years  old,  occasioned 
by  grasping  the  throat.  The  fracture  was  in  the  great  horn  of  the  right 
side,  and  the  displacement  was  so  complete  that  crepitus  could  not  be 
felt,  and  the  raucous  membrane  of  the  pharynx  was  penetrated  by  the 
broken  bone.^ 

The  following  example  is  reported  by  Dr.  Wood,  of  Cincinnati, 
Ohio,  as  having  come  under  his  observation  in  the  year  1855  : — 

"Through  the  kindness  of  our  friend  Dr.  P.  G.  Fore,  of  this  city, 
we  were  invited  to  examine  a  case  of  fracture  of  the  os  hyoides,  that 

'  Amer.  Journ.  Med.  Sci.,  vol.  xiii.  p.  250. 

2  Medic.  Vereinszeitung  fiir  Prenssen,  1833,  No.  3;  Gazette  Med.,  1834,  p.  187. 

3  Revue  Med.,  July,  1835. 


FRACTURES    OF    THE    HYOID    BONE.  135 

had  occurred  about  one  week  before  we  saw  it,  in  one  of  his  patients. 
The  patient  was  a  female,  about  thirty  years  of  age,  who  had  fallen 
down  the  cellar  steps,  striking  the  prominent  parts  of  the  larynx  and 
hyoid  bone  against  a  projecting  brick,  severely  injuring  the  larynx  as 
well  as  fracturing  the  bone. 

"The  fracture  was  on  the  left  side,  and  near  the  junction  of  the 
great  horn  with  the  body  of  the  bone.  Crepitus  was  distiuctly  felt 
on  pressing  the  bone  between  the  thumb  and  finger ;  or  when  the  pa- 
tient would  swallow;  though,  at  this  time,  the  severe  symptoms  that 
followed  the  accident,  and  continued  for  several  days,  had  somewhat 
subsided. 

"Immediately  after  the  accident  there  was  profuse  bleeding  from 
the  fauces,  and  she  experienced  great  dif&culty  and  pain  in  the  act  of 
swallowing,  and  the  power  of  speech  was  almost  entirely  lost.  On 
attempting  to  depress  or  protrude  the  tongue,  she  felt  distressing 
symptoms  of  suffocation.  Considerable  inflammation  and  swelling  of 
the  throat  and  larynx  ensued,  and  continued  in  some  degree  up  to  the 
time  of  our  visit. 

"  To-day  (about  four  weeks  since  the  accident)  Dr.  F.  informs  us 
that  the  patient  has  so  far  recovered  as  to  be  able  to  converse,  though 
the  voice  is  somewhat  impaired.  She  is  yet  unable  to  swallow  solid 
food,  and  is  wholly  sustained  by  fluids.'" 

Marcinkovsky  saw  a  woman  in  whom  both  the  lower  jaw  and  the 
left  horn  of  the  os  hyoides  were  broken  by  a  fall  from  her  carriage 
against  a  wall.    She  died  in  about  twenty-four  hours,  from  suffocation,^ 

Dr.  Griinder  reports  the  following : — 

"  A  laborer,  set.  63,  fell  from  a  wagon  on  his  face,  and  discharged 
a  large  quantity  of  blood  by  the  mouth.  He  found  he  could  not  swal- 
low, and  when  seen  twelve  hours  afterward,  complained  of  severe  pain 
in  the  neck  and  nape,  with  inability  to  turn  his  head,  though  no  in- 
jury of  the  vertebrae  could  be  detected.  His  voice  was  hoarse  and 
diffiicult.  On  attempting  to  drink,  the  fluid  was  rejected  with  violent 
coughing,  the  patient  declaring  he  felt  it  as  if  entering  the  air-passages. 
An  examination  of  the  fauces  led  to  no  explanation  of  this  condition. 
The  epiglottis  did  not,  however,  appear  to  completely  close  the  larynx, 
or  to  be  in  its  exact  position.  The  tongue  was  movable  in  all  direc- 
tions, and  pressing  it  down  with  a  spatula  caused  no  inconvenience. 
The  hyoid  seemed  to  possess  its  continuity.  No  crepitation  or  abnor- 
mal movability  could  be  perceived,  and  no  pain  at  the  root  of  the  tongue 
occurred  on  attempting  to  swallow.  After  repeated  examinations,  the 
case  was  concluded  to  be  one  in  which  the  functions  of  the  nervus 
vagus  had  undergone  great  disturbance,  or  the  muscles  of  the  larynx 
had  become  torn  or  paralyzed.  Medicine  and  food  were  administered 
by  means  of  an  elastic  tube.  The  patient  had  a  good  appetite  and 
slept  well ;  the  pain  of  the  neck  was  lost,  and  its  motion  recovered  ;  a 
hectic  cough,  from  which  he  had  long  suffered,  alone  remaining.  After 

'  Western  Lancet;  also  N.  Y.  Joum.  Med.,  vol.  xv.  p.  152. 
*  Medic.  Vereinszeitung   fiir  Preussen,  1833,  No.  15  ;   Gazette  Medicale,  1833, 
p.  854. 


136  FRACTURES    OF    THE    HYOID    BONE. 

continuing,  however,  to  go  on  thus  well  for  six  days,  the  cough  in- 
creased ;  the  appetite  failed  ;  strength  was  lost ;  the  voice  was  scarcely 
audible;  and  in  five  more  days  the  patient  died  exhausted.  At  the 
autopsy  a  fracture  of  the  os  hyoides  was  found.  One  of  the  large 
cornua  was  broken,  and  had  become  firmly  imbedded  between  the 
epiglottis  and  rima  glottidis,  inducing  the  raised  position  of  the  epi- 
glottis, loss  of  voice,  and  difficulty  in  swallowing.  The  fracture  was 
probably  produced  by  muscular  action,  a  cause  first  assigned  in  a  case 
occurring  to  Ollivier  d'Angers."^ 

I  think  it  more  probable  that  this  fracture  was  the  result  of  a  direct 
blow,  than  of  muscular  action.  In  the  case  referred  to,  however,  as 
having  been  reported  by  Ollivier,  there  can  be  no  doubt  that  the 
fracture  was  due  to  muscular  action  alone. 

A  woman,  fifty-six  years  old,  made  a  misstep  and  fell  backwards, 
and  at  the  same  moment  that  her  head  was  thrown  violently  back,  she 
felt  distinctly  a  sensation  as  if  a  solid  body  had  broken,  in  the  upper 
part  of  her  neck  and  upon  its  left  side.  An  examination  showed  that 
she  had  fractured  the  great  left  horn  of  the  os  hyoides.  Inflamma- 
tion and  suppuration  followed,  and  finally,  after  about  three  months, 
the  posterior  fragment  made  its  way  out  in  a  condition  of  necrosis, 
and  the  fistula  promptly  healed,  but  there  remained  for  many  years 
a  sense  of  uneasiness  about  these  parts  when  she  swallowed,  sometimes 
amounting  to  pain.^ 

Etiology. — Of  the  ten  cases  which  I  have  found  upon  record,  three 
were  produced  by  hanging ;  three  by  grasping  the  throat  between  the 
thumb  and  fingers;  three  by  direct  blows,  or  by  falls  upon  the  front 
of  the  neck ;  and  one  by  muscular  action  alone. 

The  observation  of  Mr.  South,  that  fracture  of  the  bone  "is  almost 
invariably  found"^  in  persons  executed  by  hanging,  is  probably  incor- 
rect, since  although  a  large  proportion  of  these  subjects  are  submitted 
to  dissection  both  in  this  and  other  countries,  yet  I  know  of  but  these 
three  examples  which  have  been  published. 

Pathology,  Symptomatology,  and  Diagnosis — The  body  of  the  bone 
seems  to  have  been  broken  in  all  of  those  cases  which  resulted  from 
hanging ;  while  in  all  of  the  other  examples  the  fracture  has  oc- 
curred in  one  of  the  great  horns,  or  at  the  junction  of  the  horns  with 
the  body.  Generally  the  displacement  inwards  of  one  of  the  frag- 
ments has  been  so  complete  that  crepitus  could  not  be  detected.  It 
was  present,  however,  in  the  examples  mentioned  by  Dieft'enbach  and 
Wood.  In  two  instances  the  mucous  membrane  has  been  penetrated, 
and  in  one  the  fragment  was  projected  between  the  epiglottis  and  rima 
glottidis. 

The  accident  has  been  characterized  by  a  sudden  sensation  as  if  a 
bone  had  broken  ;  in  a  few  instances,  by  profuse  bleeding  from  the 
fauces;  by  difiiculty  in  opening  the  mouth;  by  impossibility  of  de- 

'  Schmidt's  Jahrbuch.,  vol.  Ixviii.;  also  Amer.  Joum.  Med.  Sci.,  vol.  xlix.  p. 
353,  Jan.  1852. 
2  Malgaigne,  op.  cit.,  p.  405. 
^  Note  to  Chelius'  Surgery,  Amer.  ed.,  vol.  i.  p.  581. 


FRACTURES    OF    THE    HYOID    BONE.  18? 

glutition,  and  bj  loss  of  voice  in  others;  with  great  pain  in  moving 
the  tongue,  the  pain  being  especially  at  its  root;  in  one  instance  the 
tongue  was  perceptibly  drawn  to  one  side.  There  is  usually  more 
or  less  swelling  and  soreness  about  the  neck,  with  ecchymosis;  and 
at  a  later  period,  cough,  expectoration,  hoarseness,  &c.  The  circum- 
stances which,  however,  indicate  certainly  the  nature  of  the  accident, 
are  preternatural  mobility  of  the  fragments,  with  or  without  crepitus, 
and  the  angular,  inward  projection,  which  may  in  most  cases  be  dis- 
tinctly felt  in  a  careful  examination  of  the  pharynx. 

In  the  case  related  by  Griiner,  the  only  symptoms  were  a  loss  of 
voice,  difficulty  of  deglutition,  and  a  sensation,  when  the  attempt  was 
made  to  swallow,  as  if  the  fluids  passed  into  the  windpipe;  with  also 
an  imperfect  closure  of  the  epiglottis  upon  the  rima  glottidis.  No 
preternatural  mobility  or  irregularity  in  the  fragments  could  be  de- 
tected, nor  was  there  crepitus,  and  it  was  concluded  that  the  bone  was 
not  broken,  yet  the  autopsy  showed  that  the  fragment  was  imbedded 
deeply  between  the  epiglottis  and  the  rima  glottidis. 

Prognosis. — It  is  only  in  view  of  its  complications  that  this  acci- 
dent can  be  regarded  as  serious ;  where  the  severity  of  the  injury  has 
been  such  as  to  fracture  the  lower  jaw  at  the  same  time,  as  in  the  case 
related  by  Marcinkovsky,  or  such  as  to  bury  the  fragment  deep  in 
the  tissues  about  the  rima  glottidis,  as  in  the  case  mentioned  by 
Griiner,  a  favorable  termination  could  scarcely  have  been  expected ; 
and  these  are  the  only  cases  yet  published  in  which  the  death  was  in 
any  way  connected  with  the  fracture.  One-half  of  the  whole  number 
have  died,  but  of  these,  three  have  died  by  hanging,  and  the  remain- 
ing two  from  the  causes  named.  Of  the  three  in  which  the  accident 
resulted  from  a  direct  blow,  only  the  patient  of  Dr.  Fore,  of  Cincin- 
nati, has  survived ;  while  of  the  three  whose  fractures  resulted  from 
lateral  pressure  upon  the  cornua,  all  recovered ;  so,  also,  did  the  pa- 
tient in  whom  the  fracture  was  produced  by  muscular  action. 

Treatment. — No  doubt  when  the  fragments  are  displaced  an  attempt 
ought  to  be  made  to  replace  them  by  introducing  one  finger  into  the 
mouth,  while  with  the  opposite  hand  the  fragments  are  supported  from 
without.  Lalesque  found  this  a  matter  of  some  difficulty,  but  Auberge 
experienced  no  difficulty  at  all.  I  suspect,  however,  that  the  amount 
of  difficulty  will  very  much  depend  upon  the  degree  of  displacement, 
and  the  consequent  lacerations  of  the  soft  tissues  about  the  bone.  But 
however  this  may  be,  it  must  be  altogether  another  thing  to  be  able 
to  keep  in  exact  apposition  the  broken  ends  of  a  bone  whose  diameter 
is  so  inconsiderable,  and  upon  which  it  is  quite  impossible  to  apply 
any  apparatus  or  dressings  to  retain  the  fragments  in  place.  Lalesque 
threw  the  head  of  his  patient  slightly  back,  with  the  view  of  making 
"  permanent  extension"  upon  the  fragments  through  the  action  of  the 
muscles  and  ligaments  attached  to  the  bone,  and  he  recommends  this 
position  as  that  which  is  best  calculated  to. preserve  the  coaptation. 
Malgaigne,  on  the  contrary,  without  having  himself  seen  any  example 
of  this  fracture,  believes  that  the  position  of  flexion  of  the  neck,  with 
entire  relaxation  of  the  muscles,  would  be  most  suitable. 

In  all  cases  it  will  be  proper  to  enjoin  silence,  and  to  adopt  suit- 
10 


138      FRACTUKE    OF    THE    CARTILAGES    OF    THE    LARYNX. 

able  measures  to  combat  inflammation;  such  as  general  or  topical 
bleeding,  fomentations,  moistening  the  mouth  with  cool  water,  or  per- 
mitting small  pieces  of  ice  to  rest  in  the  mouth  until  dissolved,  without 
in  general  allowing  the  fluid  to  be  swallowed  ;  but  in  some  examples, 
no  doubt,  the  patient  may  be  permitted  to  swallow. 


CHAPTER    XIV. 

FRACTURE  OF  THE  CARTILAGES  OF  THE  LARYNX. 
§  L  Thyroid  Cartilage. 

The  examples  of  fracture  of  the  larynx  which  may  be  found  upon 
record  are  also  very  few.  M.  Ladoz  examined  the  larynx  of  a  man 
who  had  been  assassinated,  and  upon  whose  neck  he  found  a  hand- 
kerchief bound  so  tightly  as  to  leave,  after  its  removal,  a  deep  farrow  ; 
but  the  neck  showed  also  distinct  marks  produced  by  the  fingers  and 
thumb.  There  was  a  fracture  of  the  thyroid  cartilage  which  extended 
obliquely  downwards  and  outwards  through  its  right  wing.  The  whole 
of  the  larynx  was  very  much  ossified,  although  the  subject  was  only 
thirty-seven  years  old.^ 

In  1823,  M.  Ollivier  communicated  to  the  Academy  of  Medicine  a 
case  in  which,  this  cartilage  being  broken,  the  patient  died  of  suffo- 
cation.^ 

M.  Marjolin  says :  "  Two  women  at  the  hospital  being  engaged  in  a 
quarrel,  one  of  them  seized  her  antagonist  by  the  throat,  and  griped 
her  so  strongly  that  she  broke  the  thyroid  cartilage  from  its  upper  to 
its  lower  margin.  You  will  imagine  that  it  was  not  very  difficult  to 
determine  the  existence  of  a  fracture,  and  that  no  retentive  apparatus 
was  demanded.  Silence,  regimen,  a  small  bleeding,  and  the  cure  was 
accomplished."^ 

Habicot  operated  successfully,  in  1620,  by  introducing  a  leaden 
tube  into  the  trachea  in  a  case  in  which  the  thyroid  was  "damaged." 
Gibb,  Norris,  Nelaton,  and  Kenderline  have  each  reported  examples 
of  fracture  of  this  cartilage  alone.* 


§  2.  Thyroid  and  Cricoid  Cartilages. 

Plenck  saw  a  fracture  of  both  the  thyroid  and  cricoid  cartilages 
produced  by  falling  upon  the  rim  of  a  pail.^  Morgagni  also  says 
that  he  had  seen  fractures  of  the  larynx ;  and  Remer  mentions  a  frac- 

1  Gazette  Medicale,  1838,  p.  698. 

2  Archives  Generales  de  Medecine,  tome  ii.  p.  307. 

*  Marjolin,  Cours  de  Patholog.  Chir.,  p.  396. 

'  Hunt,  Frac.  of  Larj^nx,  &c.     Am.  Journ.  Med.  Sci.,  April,  1866. 

*  Malgaigne,  op.  cit.,  p.  409. 


THYEOID    AND    CEICOID    CARTILAGES.  139 

ture  of  the  larynx  found  in  a  person  who  had  been  hanged  ;^  but  in 
neither  case  is  it  said  in  which  cartilage  the  fracture  occurred,  or 
whether  it  had  not  occurred  in  both. 

Dr.  O'Brian,  of  Edinburgh,  reports  in  vol.  xviii.  of  the  Edinburgh 
Med.  and  Surg.  Journ.,  a  case  of  fracture  of  both  cartilages,  involving 
the  trachea  also,  in  a  woman  who  had  received  a  kick  under  the  jaw, 
and  who  died  on  the  following  day.  Hunt  has  collected  other  cases, 
some  of  which  involved  the  arytenoid  cartilages,  the  hyoid  bone,  the 
trachea,  &c. 

I  am  able  to  furnish,  from  my  own  observation,  another  example 
of  fracture  of  both  the  thyroid  and  cricoid  cartilages : — 

John  Calkins,  of  Collins,  Erie  Co.,  N.  Y.,  £et.  41,  is  supposed  to  have 
been  kicked  by  a  young  horse  on  the  10th  of  Nov,  1856.  He  was 
alone  in  the  stables  when  the  accident  occurred,  and,  being  stunned 
by  the  blow,  he  could  not  himself  give  any  account  of  the  manner  in 
which  the  injury  was  received.  When  found,  he  was  sitting  upright, 
but  unable  to  articulate  except  in  a  whisper.  Drs.  Barber  and  Davis, 
of  Colden,  saw  him  about  two  hours  after.  His  countenance  was 
anxious;  his  pulse  feeble;  extremities  cold;  and  he  was  breathing 
with  great  difficulty.  A  small  quantity  of  blood  was  issuing  from  his 
fauces.  His  upper  lip  was  cut,  and  a  few  of  his  teeth  dislocated  ;  the 
wound  appearing  as  if  inflicted  by  one  of  the  corks  of  the  horse's 
shoes.  There  was  no  other  wound;  but  over  the  left  wing  of  the 
thyroid  cartilage  there  was  a  slight  discoloration,  pressure  upon  which 
produced  intense  pain  and  suftbcation,  and  disclosed  the  fact  that  the 
thyroid  prominence  was  depressed  very  much  and  broken.  Cold 
lotions  were  directed  to  be  applied,  and  as  the  thirst  was  excessive, 
but  deglutition  impossible,  he  was  permitted  to  hold  pieces  of  ice  in 
his  mouth.  This  plan,  with  but  alight  modifications,  such  as  the  sub- 
stitution of  warm  fomentations  to  the  neck  for  the  cold  lotions,  was 
continued  until  the  following  evening,  when,  at  the  request  of  the 
attending  physician,  Dr.  Barber,  I  was  called  to  see  him.  The 
symptoms  remained  nearly  the  same  as  at  first.  He  was  unable  to 
speak  audibly,  or  perform  the  act  of  deglutition;  his  breathing  was 
difficult,  and  at  times  threatened  sufibcation.  The  lateness  of  the 
hour,  with  other  circumstances,  determined  me  to  defer  surgical 
interference  until  morning.  At  daybreak  of  the  12th  I  made  the 
operation  of  laryngotomy,  and  introduced  a  large  double  canula  into 
the  crico-thyroidean  space.  This  operation  was  rendered  difficult  by 
the  great  amount  of  swelling  about  the  neck,  due  both  to  emphysema, 
and  bloody  with  serous  infiltrations.  The  breathing  immediately 
became  easy,  and  gradually  the  appearance  of  asphyxia  disappeared 
from  his  face ;  but  after  about  six  or  seven  hours  he  began  percepti- 
bly to  fail  in  strength,  and  died  at  3  o'clock  P.  M.  of  the  following 
day,  apparently  from  exhaustion  rather  than  from  sufibcation  ;  having 
survived  the  accident  about  seventy-two  hours,  and  the  operation 
about  thirty-four  hours. 

'  Morgagni,  de  Sedibus,  etc.,  Epist.  19,  num.  13,  14,  et  16;  Remer,  Aunales 
d' Hygiene,  tome  iv.  p.  171  ;  from  Malgaigne. 


140      FRACTURE    OF    THE    CARTILAGES    OF    THE    LARYNX. 

The  autopsy  disclosed  a  comminuted  fracture  of  the  thyroid  carti- 
lage, with  a  simple  fracture  of  the  cricoid.  The  thyroid  was  broken 
almost  perpendicularly  through  the  centre;  the  line  of  fracture  being 
irregular,  and  inclining  slightly  to  the  left  side.  The  left  inferior  horn 
was  broken  off  about  three  lines  from  its  articulation  with  the  cricoid 
cartilage.  The  right  ala  was  broken  also  in  a  line  nearly  vertical,  but 
irregular,  at  a  point  about  six  lines  from  its  posterior  margin.  The 
pomum  Adami  was  depressed  to  the  level  of  the  cricoid  cartilage, 
and  the  left  ala,  being  completely  detached,  was  thrown  inwards  and 
upwards  several  lines.  Underneath  the  perichondrium,  especially 
upon  the  inner  side,  there  was  pretty  extensive  bloody  infiltration. 
Ossification  of  the  cartilages  had  commenced  at  several  points,  but  it 
had  made  but  little  progress.  The  central  fracture  of  the  thyroid 
was  through  cartilage  alone.  The  fracture  of  the  right  ala  was 
through  cartilage  until  it  reached  a  bony  belt  comprising  the  two 
inferior  lines  of  its  course.  The  left  lower  horn  was  ossified,  and  the 
fracture  was  through  this  bony  structure.  The  fracture  through  the 
cricoid  cartilage  commenced  close  upon  the  margin  of  a  bony  plate, 
but  in  its  whole  course  it  traversed  only  cartilage.  It  was  on  the  left 
side.  There  was  also  an  incomplete  fracture  on  the  right  ala  of  the 
thyroid  cartilage,  commencing  in  the  line  of  the  principal  fracture 
and  extending  obliquely  downwards  about  three  lines,  until  it  was 
arrested  by  the  bony  plate  which  constituted  the  lower  margin  of 
this  wing. 

A  ragged,  lacerated  wound  in  the  back  of  the  larynx,  above  the 
cricoid  cartilages,  communicated  directly  with  the  oesophagus. 

§  3.  Cricoid  Cartilage. 

Both  Valsalva  and  Cazauvi^ilh  have  each  met  with  a  single  exam- 
ple of  this  fracture,  without  fracture  of  the  thyroid  cartilage;  and 
Weiss  has  found  the  cricoid  cartilage  broken  into  numerous  frag- 
ments, and  at  the  same  time  separated  from  the  trachea.^ 

General  Etiology  of  Fractures  of  the  Laryngeal  Carti- 
lages.— As  a  predisposing  cause,  advanced  age,  with  its  usual  con- 
comitant, partial  or  complete  ossification  of  the  cartilages,  has  been 
thought  to  occupy  a  prominent  place.  In  the  case  reported  by  Plenck, 
the  cartilages  were  already  very  much  ossified,  although  the  subject 
was  only  thirty-seven  years  old.  Morgagni  observed  that  in  his 
experience  it  had  occurred  always  in  advanced  life.  In  my  own 
ease,  however,  the  cartilages  were  only  slightly  ossified,  the  patient 
being  forty-one  years  old;  nor  did  the  lines  of  the  several  fractures 
indicate  a  preference  for  the  bony  plates;  but  it  seems  to  me  that  they 
rather  avoided  them,  and  in  the  case  of  the  incomplete  fracture  the 
bone  appeared  to  have  arrested  the  fracture.  In  fact,  a  few  experi- 
ments have  satisfied  me  that  the  adult  laryngeal  cartilages  are  quite 

'  Malgaigne,  op.  cit.,  p.  408. 


CRICOID    CARTILAGE.  141 

as  brittle  as  bone,  and,  consequently,  that  ossification  in  no  way  in- 
creases their  liability  to  fracture. 

Hunt  ascertained  the  age  in  fifteen  cases,  and  but  one  of  the  whole 
number  was  over  45  3'ears ;  five  occurred  in  children,  one  of  whom 
was  only  four  years  old. 

The  immediate  causes  have  been  direct  blows,  as  falling  upon  the 
edge  of  a  pail,  a  kick  from  a  horse,  or  pressure,  as  in  hanging,  or  in 
grasping  the  larynx  strongly  between  the  thumb  and  fingers. 

General  Symptomatology,  etc. — The  signs  of  this  accident  are 
such  as  may  attend  any  severe  injury  of  this  organ,  whether  accom- 
panied with  a  fracture  or  not,  such  as  pain,  swelling,  difficult  degluti- 
tion, embarrassed  respiration,  loss  of  voice,  cough,  and  perhaps  bloody 
expectoration,  with  emphysema,  &c. 

But  none  of  these  can  be  regarded  as  diagnostic;  although,  when 
taken  in  connection  with  the  history  of  the  accident,  especially  if  a 
very  severe  and  direct  blow  has  been  received,  or  more  certainly  still 
when  symptoms  so  grave  and  complicated  have  followed  an  attempt 
at  strangulation  by  grasping  the  throat,  they  may  be  regarded  as  pro- 
bable or  presumptive  evidences. 

A  positive  diagnosis  must  depend  upon  the  presence  of  a  sensible 
displacement,  or  motion  of  the  fragments,  with  crepitus. 

In  the  case  related  by  Plenck,  death  followed  almost  immediately, 
with  convulsions,  and  without  any  outcry  ;  indicating,  probably,  some 
severe  lesion  of  the  spinal  marrow;  while  in  M.  Ollivier's  patient  suffo- 
cation ensued,  at  first  intermittent,  and  finally  permanent. 

In  my  own  case,  suffocation  was  throughout  a  prominent  symptom, 
with  only  such  slight  intervals  of  amelioration  as  might  have  been 
occasioned  by  the  extrication  of  the  blood  or  mucus  from  the  larynx. 

General  Prognosis. — The  prognosis  ought  to  depend  rather  upon 
the  complications  and  upon  the  gravity  of  the  symptoms,  than  upon 
the  simple  decision  of  the  question  of  fracture.  A  fracture  produced 
by  grasping  the  wings  of  the  thyroid  cartilage,  and  without  any  great 
contusion  or  laceration  of  the  soft  parts,  might  reasonably  be  expected 
to  terminate  favorably  under  judicious  management ;  but  when,  on  the 
contrary,  the  fracture  is  the  result  of  great  violence  inflicted  directly 
upon  the  front  of  the  cartilages,  producing  severe  contusion  and  lace- 
ration, and  is  followed  by  great  swelling,  emphj^sema,  very  difficult 
respiration,  complete  aphonia,  impossibility  of  deglutition,  &c.,  the 
prognosis  cannot  but  be  unfavorable. 

General  Treatment. — In  examples  of  simple,  uncomplicated  frac- 
ture, "  silence,  regimen,  and  a  small  bleeding"  may  suffice ;  but  in  other 
cases  it  may  become  necessary  to  introduce  a  tube  into  the  stomach, 
to  supply  the  patient  with  food  and  drinks,  since  deglutition  may  be 
impossible.  If,  also,  suffocation  is  imminent,  there  may  remain  no 
alternative  but  a  resort  to  tracheotomy  or  to  laryngotomy. 

Indeed,  one  of  these  operations  ought,  we  think,  to  be  resorted  to  in 
all  cases  in  which  emphysema  is  prominent.     Dr.  William  Hunt,  of 


142  FRACTURES    OF    THE    VERTEBRAE. 

the  Pennsylvania  Hospital,  in  his  excellent  paper  on  "Fractures  of  the 
Larynx  and  Euptures  of  the  Trachea,"  in  which  he  has  arranged  a 
tabular  synopsis  of  twenty-nine  cases,  says  that  of  twenty-seven  cases 
ten  recovered  and  seventeen  died.  Of  eight  cases  in  which  tracheo- 
tomy was  performed,  but  two  died.  In  the  four  cases  in  which  recovery 
took  place  without  an  operation  no  mention  is  made  of  bloody  expec- 
toration or  of  emphysema.* 

As  to  a  "reduction"  of  the  fragments  by  manipulation,  I  believe  it 
■will  be  found  generally,  if  not  always,  impracticable.  Whatever  dis- 
placement exists  must  be  mostly  inwards,  and  we  can  have  no  means 
of  forcing  them  again  outwards.  Nor,  if  once  replaced,  do  I  see  any 
reason  to  suppose  that  they  would  not  become  immediately  displaced. 

Chelius  has  suggested  the  propriety,  in  such  cases,  of  cutting  open 
the  coverings  of  the  larynx  freely  in  the  median  line,  and,  after  stanch- 
ing the  bleeding,  proceeding  at  once  to  divide  the  larynx  itself  in  its 
whole  length,  and  then  replacing  the  broken  cartilages.^  The  pro- 
cedure has  an  aspect  of  severity,  but  I  can  well  conceive  of  circum- 
stances which  would  justify  its  adoption;  not,  however  so  much  for 
the  purpose  of  replacing  the  cartilages,  as  for  the  purpose  of  arresting 
a  fatal  internal  hemorrhage,  and  of  giving  a  free  admission  of  air  to 
the  lungs.  If  this  operation  were  to  be  practised,  the  wound  ought 
to  be  left  open  for  a  sufficient  leiigth  of  time  to  allow  of  the  subsi- 
dence of  the  inflammation,  and  then  permitted  to  close  with  such 
precautions  as  experience  teaches  are  usually  necessary  after  the 
windpipe  has  been  opened. 

Active  antiphlogistic  measures,  combined  with  fomentations  to  the 
neck,  so  far  as  these  latter  are  found  to  be  agreeable  and  practicable, 
are  important  measures,  and  not  to  be  overlooked  in  the  general  plan 
of  treatment. 

My  own  patient,  also,  found  small  pieces  of  ice,  permitted  slowly  to 
dissolve  in  the  mouth,  very  grateful ;  but  he  preferred  very  much,  as 
an  external  application,  the  warm  fomentations  to  the  cold  lotions. 


CHAPTER    XV. 

FRACTURES  OP  THE  VERTEBRA. 

It  will  be  convenient  to  divide  fractures  of  the  vertebrae  into  frac- 
tures of  the  spinous  processes,  transverse  processes,  vertebral  arches, 
and  bodies. 

§  1 .  Fractures  of  the  Spinous  Processes. 

Fractures  of  the  spinous  apophyses,  independent  of  a  fracture  of  the 
arches,  may  occur  at  any  point  of  the  vertebral  column;  and  they 

'  Hunt,  Amer.  Joiirn.  Med.  Sci.,  April,  1866. 

2  System  of  Surgery,  Philadelphia  ed.,  vol.  i.  p.  581,  1847. 


FRACTURE    OF    THE    SPINOUS    PROCESSES. 


143 


Fior.  32. 


may  be  occasioned  by  a  blow  received  upon  either  side  of  the  spinal 
column;  or  by  a  force  directed  from  above  or  from  below. 

Symptoms  and  Pathology. — These  accidents  may  be  recognized  by 
the  lively  pain  at  the  point  of  fracture,  produced  especially  when  the 
patient  bends  forwards,  which  position  renders  the  skin  and  muscles 
tense  and  drives  the  fragments  into  the  flesh;  by  the  swelling,  ten- 
derness, and  discoloration;  but  chiefly  by  the  lateral  displacement  of 
the  broken  process,  and  the  mobility. 

Duverney  met  with  a  fracture  of  two  of  the  processes  in  the  same 
person,  and  which  could  only  be  recognized  by  the  mobility,  since, 
as  the  autopsy  proved,  there  was  no  dis- 
placement. Nor  would  it  be  surprising 
if  the  displacement  was  absent  in  a  ma- 
jority of  these  accidents,  inasmuch  as  the 
attachment  of  the  ligaments  from  above 
and  below  with  the  strong  and  short 
muscles  upon  either  side,  must  prevent 
a  deviation  in  any  direction  until  these 
tissues  were  more  or  less  torn.  Sir  Astley 
mentions  a  case  in  which,  however,  such 
lacerations  did  occur,  and  the  lateral  de- 
formity was  quite  conspicuous. 

A  boy  had  been  endeavoring  to  sup- 
port a  heavy  weight  upon  his  shoulders, 
when  he  fell  bent  double.  Immediately 
he  had  the  appearance  of  one  suffering 
under  a  distortion  of  the  spine  of  long 
standing.  Three  or  four  of  the  processes  were  broken  off,  and  the 
corresponding  muscles  were  detached  so  as  to  allow  the  processes  to 
fall  off  to  the  opposite  side.  There  was  no  paralysis,  and  he  was 
soon  discharged  with  the  free  use  of  his  limbs,  but  the  deformity 
remained.^ 

If  the  fragment  is  thrown  directly  downwards,  as  it  possibly  may 
be,  especially  in  the  cervical  or  lumbar  region,  yet  not  without  a  rup- 
ture of  the  supra-spinous  ligaments,  or  of  the  ligamentum  nuchce,  then 
the  displacement  will  be  more  difficult  to  detect,  and  it  may  require 
some  more  care  not  to  confound  it  with  a  fracture  of  the  vertebral 
arch  or  of  the  plates  from  which  the  spinous  processes  arise.  The 
process  not  being  felt  in  its  natural  position,  nor  upon  either  side,  it 
may  seem  to  have  been  forced  directly  forwards,  when  in  fact  it  is 
only  thrown  downwards  towards  its  fellow.  The  danger  of  error  in 
the  diagnosis  will  be  increased  when  to  these  conditions  are  added 
paralysis  of  those  portions  of  the  body  which  are  below  the  seat  of 
the  fracture,  and  which,  in  this  case,  may  be  the  result  of  an  extra- 
vasation of  blood  or  of  simply  a  concussion  of  the  spinal  marrow.  Nor 
do  I  think  it  would  be  possible  now  to  determine  positively  whether 
it  was  simply  a  fracture  of  a  spinous  process,  of  the  arch,  or  of  the 
body  itself  of  the  vertebra.     In  case,  however,  the  paralysis  results 


Fracture  of  the  spinous  process. 


'  Sir  Astley  Cooper,  op.  cit.,  p.  459. 


144  FKACTURES  OF  THE  VERTEBRA. 

from  concussion,  the  fact  will  in  most  cases  soon  become  apparent  by 
a  return  of  sensation  and  of  the  power  of  motion. 

Prognosis. — Hippocrates  affirmed  that  here,  as  in  fractures  of  other 
spongy  bones,  the  union  took  place  speedily.  It  is  quite  probable 
that  this  venerable  father  of  surgery  has  stated  the  fact  correctly,  and 
yet  in  the  only  example  known  to  me  where  the  condition  of  this 
process,  as  proved  by  dissection,  has  been  carefully  stated,  the  frag- 
ment had  not  united  by  bone  at  all.  This  is  the  case  related  by  Sir 
Astley  as  having  been  examined  by  Mr.  Key.  A  subject  was  brought 
into  the  dissecting-room,  in  which  one  of  the  processes  had  been 
broken,  and,  on  dissection,  a  complete  articulation  was  found  between 
the  broken  surfaces,  which  surfaces  had  become  covered  with  a  thin 
layer  of  cartilage.  The  false  articulation  was  surrounded  with  sy- 
novial membrane  and  capsular  ligaments,  and  contained  a  fluid  like 
synovia.' 

Ordinarily  the  displacement  continues,  whatever  treatment  may  be 
adopted ;  but  Malgaigne  says  he  has  seen  one  instance  in  which  the 
twelfth  dorsal  spine,  being  broken  and  displaced  laterally,  resumed 
its  place  spontaneously  after  a  few  days.  Aurran  mentions  a  similar 
example.^ 

Treatment. — If  in  any  case  it  should  be  found  possible  to  act  upon 
the  fragment,  an  attempt  might  be  made  to  press  it  into  place,  and  to 
retain  it  there  by  means  of  a  compress  and  bandage;  but  even  this 
would  not  be  admissible  so  long  as  any  doubt  remained  whether  it 
was  not  a  fracture  of  the  vertebral  arch,  since,  if  it  were,  any  attempt 
to  restore  the  bone  to  place  by  pressure  would  be  likely  to  drive  it 
more  deeply  upon  the  spinal  marrow.  Yet  what  need  is  there  of 
surgical  interference  of  any  kind  ?  If  the  apophysis  remains  displaced 
it  cannot  result  in  any  serious,  perhaps  we  may  say  in  any  appreciable, 
deformity.  The  surgeon  has  therefore  only  to  lay  the  patient  quietly 
in  bed  and  in  such  a  position  as  he  finds  most  comfortable,  enjoining 
upon  him  perfect  rest,  and  employing  such  other  means  as  may  be 
proper  to  combat  inflammation. 

§  2.  Fractures  op  the  Transverse  Process. 

A  fracture  of  a  transverse  process  can  scarcely  occur  except  as  a 
consequence  of  a  gunshot  wound.  Dupuytren  relates  a  case  of  this 
kind  in  which  the  ball  had  penetrated  the  transverse  process  of  the 
second  cervical  vertebra.  The  man  bled  very  little  at  the  time,  and 
his  symptoms  progressed  favorably  for  ten  days  ;  after  which  second- 
ary hemorrhage  occurred,  of  which  he  ultimately  died.  The  autopsy 
showed  that  the  vertebral  artery  had  been  injured,  and  that  the  inflam- 
mation of  its  coats  being  followed  by  a  slough,  caused  his  death.' 

I  have  also  elsewhere  reported  the  case  of  Charles  Harkner,  of  Buffalo, 
N.  Y.,  who  was  shot  with  a  pistol  on  the  21st  of  Jan.  1851.  I  did  not 
see  him  until  the  following  day.  The  ball  had  entered  the  chin,  a  little 

'  A.  Cooper,  op.  cit.,  p.  459.  2  Malgaigne,  op.  cit.,  p.  413. 

^  Dupuytren,  Diseases,  &c.  of  Bones,  Syd.  ed. ,  p.  360. 


FEACTURES  OF  THE  VERTEBRAL  ARCHES. 


145 


to  the  left  side  and  below  the  inferior  maxilla,  but  its  place  of  lodgement 
could  not  be  discovered.  He  lay  with  his  face  constantly  turned  to 
the  right.  The  left  side  of  his  neck  was  swollen  and  crepitant ;  the  left 
arm  and  leg  were  paralyzed ;  he  slept  most  of  the  time,  but  could  be 
easily  aroused,  and  when  aroused  he  seemed  to  be  conscious,  but  was 
unable  to  speak.  By  signs  he  indicated  to  us  that  he  was  suffering 
no  pain.  He  gradually  sank,  without  hemorrhage,  and  died  in  thirty- 
six  hours  from  the  time  of  the  receipt  of  the  injury. 

The  autopsy,  made  four  hours  after  death, 'enabled  us  to  trace  the 
wound  from  the  chin,  through  the  leftala  of  the  thyroid  cartilage,  and 
also  through  the  roots  of  the  transverse  process  of  the  fourth  cervical 
vertebra;  immediately  behind  which,  lying  imbedded  in  the  muscles, 
was  the  bullet.  The  cavity  of  the  tunica  arachnoides  contained  con- 
siderable serous  effusion. 

The  emphysema  in  the  neck  was  occasioned,  no  doubt,  by  the 
wound  of  the  larynx,  the  ball  having  opened  freely  into  its  cavity. 
This  circumstance  also  explained  the  aphonia ;  but  the  immediate 
cause  of  his  death  seems  to  have  been  arachnoid  effusion  as  a  result 
of  meningeal  inflammation. 

The  symptoms  arising  from  this  accident  can  only  refer  to  the  com- 
plications, since  a  mere  fracture  of  the  process  is  not  likely  to  present 
any  peculiar  signs  which  could  be  recognized.  Concussion  or  bloody 
effusion  may  take  place  so  as  to  occasion  more  or  less  paralysis,  or, 
at  a  later  period,  inflammation  and  its  consequent  effusions  may  give 
rise  to  the  same  phenomenon. 

In  itself  considered,  and  independent  of  these  complications,  it  is 
sufficiently  trivial,  but  inasmuch  as  it  has  not  been  known  to  occur 
except  from  gunshot  wounds,  nor  is  it  likely  to  occur  except  from 
penetrating  wounds  of  some  kind,  the  accident  must  always  be  re- 
garded as  exceedingly  grave,  if  not  actually  fatal. 

As  to  the  treatment,  nothing  but  strict  rest  and  antiphlogistic 
remedies  can  prove  of  any  service. 


§  3.  Fractures  op  the  Vertebral  Arches. 


The  vertebral  arches,  upon  which  both 
the  spinous  and  transverse  processes  have 
their  pi-incipal  support,  may  be  broken 
at  any  point  of  their  circumference,  by  a 
blow  received  upon  the  spinous  process; 
but  generally  it  is  the  lamellar  portion, 
or  the  "  vertebral  plate,"  which  gives  way 
rather  than  the  neck  or  pedicle  of  the 
arch ;  and  in  all  of  the  cases  recorded 
the  plates  have  been  broken  upon  both 
sides. 

On  the  first  of  May,  18>1,  during  a 
violent  storm  of  wind  and  -ain,  a  balus- 
trade fell  from  the  top  of  a  high  build- 
ing, striking  a  man  named  John  Larkin, 


Fig.  33. 


Fracture  of  the  vertebral  arch. 


146  FRACTURES  OF  THE  VERTEBRA. 

who  was  about  forty  years  of  age,  upon  the  back  of  his  head  and  neck. 
He  fell  to  the  ground  instantly,  and  did  not  again  move  his  feet  or 
legs,  although  he  never  lost  his  consciousness  until  he  died.  I  found 
the  bladder  paralyzed  also,  and  his  left  arm,  but  his  right  arm  he 
could  move  pretty  well.  He  conversed  freely  up  to  the  last  moment, 
and  said  that  he  was  suffering  a  good  deal  of  pain,  which  was  always 
greatly  aggravated  by  moving.  His  death  took  place  thirty-six 
hours  after  the  receipt  of  the  injury. 

Dr.  Hugh  B.  Vandeventer,  who  was  the  attending  surgeon,  made  a 
dissection  on  the  following  day  in  my  presence,  which  disclosed  the 
fact  that  the  plates  of  the  sixth  cervical  vertebra  were  broken  upon 
each  side,  and  that  the  spinous  process,  with  a  small  portion  of  the  arch 
attached,  was  forced  in  upon  the  spinal  marrow.  There  was  no  blood 
effused,  or  serum  at  this  point,  but  about  one  ounce  of  serum  was 
found  in  the  cavity  of  the  tunica  arachnoides  at  the  base  of  the  brain. 
The  bodies  of  the  vertebrae  were  not  broken.  It  was  our  opinion, 
therefore,  that  the  immediate  cause  of  his  death  was  the  direct  pres- 
sure of  the  spinous  process. 

In  the  case  related  by  Prout,  of  Alabama,  the  man  having  died 
within  forty-eight  hours  after  the  receipt  of  the  injury,  the  arch  of  the 
fifth  cervical  vertebra  was  found  to  be  broken  in  three  places,  and  the 
spinous  process  was  driven  in  upon  the  spinal  marrow.  There  was 
a  slight  effusion  of  blood  between  the  sheath  of  the  spinal  marrow 
and  the  bone,  and  a  considerable  effusion  between  the  sheath  and  the 
cord.  There  was  no  material  lesion  of  the  cord  or  of  its  membranes, 
and  the  body  of  the  bone  was  neither  broken  nor  dislocated.* 

It  is  probable,  also,  that  in  the  following  example  the  arch  was 
broken,  but  that  the  force  of  the  blow  having  been  somewhat  oblique, 
the  process  was  but  little  if  at  all  thrown  in  upon  the  spinal  marrow. 

E.  L.,  of  Erie  County,  N.  Y.,  aged  about  forty  years,  was  thrown 
from  a  loaded  wagon  in  February  of  1851,  striking,  as  he  thinks,  upon 
the  back  of  his  neck.  He  was  stunned  by  the  injury,  and  remained 
insensible  several  hours ;  on  the  return  of  consciousness,  he  found  that 
his  lower  extremities  and  bladder  were  paralyzed.  During  four  weeks 
his  bladder  had  to  be  emptied  by  a  catheter.  Nine  months  after  the 
injury  was  received  he  consulted  me,  and  I  found  the  spinous  process 
of  the  last  cervical  vertebra  pushed  over  to  the  left  side.  His  head 
was  strongly  bent  forwards,  and  he  was  unable  to  straighten  it.  He 
could  walk  a  few  steps,  but  not  without  great  fatigue ;  and  he  suffered 
almost  constant  pain  in  his  lower  extremities,  accompanied  with  ex- 
cessive restlessness  and  watchfulness,  for  which  he  was  obliged  to  take 
morphine  in  large  quantities. 

In  the  case  related  by  Alban  G.  Smith,  of  Kentucky,  to  which  I 
shall  refer  again  presently,  the  deviation  was  lateral,  and  so  also  in 
Ollivier's  case,  mentioned  by  Malgaigne. 

Symptoms. — We  can  imagine  a  case  of  fracture  of  the  vertebral  arch, 
with  a  lateral  displacement  only,  in  which  the  symptoms  might  not 

'  Prout,  Amer.  Journ.  Med.  Sci.,  Nov.  1837,  vol.  xxi.  p.  276,  from  Western  Journ. 
of  Med.  and  Phys.  Sci. 


FRACTURES  OF  THE  VERTEBRAL  ARCHES.      147 

differ  essentially  from  a  simple  fracture  of  the  spinous  process ;  and 
it  is  quite  possible  that  some  of  the  cases  which  have  been  supposed 
to  be  examples  of  this  latter  accident,  and  in  which  a  speedy  recovery 
has  taken  place,  were  really  examples  of  fracture  of  the  arches;  yet  it 
must  be  admitted  that  such  a  fortunate  result  is  only  possible,  since 
the  arches  can  hardly  be  broken  without  communicating  a  severe 
concussion  to  the  marrow,  nor  without  lacerations,  inflammation,  and 
effusions,  which  will  be  most  certain  to  produce  compression  and 
paralysis,  and  probably  death. 

If,  however,  it  is  possible  for  us  to  confound  a  fracture  of  the  process 
with  a  fracture  of  the  arches,  it  is  still  more  possible  for  us  to  confound 
a  fracture  of  the  arches  with  a  fracture  of  the  bodies  of  the  vertebrae. 
If,  as  is  usually  the  fact,  the  process,  in  case  of  a  fracture  of  the  arch, 
is  less  prominent  than  natural,  and  that  portion  of  the  body  receiving 
its  nervous  supply  from  below  this  point  is  paralyzed,  we  may  have 
reasons  to  believe  that  the  arch  is  broken  and  the  process  driven  in 
upon  the  spine;  but  dissections  have  shown  that  in  many  of  these 
cases,  or  in  most  of  them,  indeed,  the  bodies  of  more  or  less  of  the 
vertebras  are  broken  also,  and  in  still  other  cases  the  bodies  were 
alone  broken. 

If,  as  in  the  case  mentioned  by  Ollivier,  we  can  feel  the  plates  move 
separately,  the  diagnosis  might  be  made  out,  so  far  at  least  as  to  deter- 
mine that  the  plates  were  broken ;  but  we  should  be  still  unable  to 
say  that  the  bodies  of  the  vertebrge  were  not  broken  also. 

Something  perhaps  may  be  inferred  from  the  direction  and  manner 
of  the  blow  which  has  produced  the  fracture.  Thus,  a  fall  upon  the 
top  of  the  head  would  most  often  produce  a  comminution  of  the  bodies 
by  crushing  them  together,  while  a  blow  upon  the  back  could  scarcely 
break  one  of  the  vertebrae  without  breaking  the  corresponding  arch 
also.  We  might  thus  be  led  to  infer,  in  the  first  instance,  that  the 
arches  were  not  broken;  and,  in  the  second  instance,  if  we  could  con- 
vince ourselves  that  the  arches  were  not  broken,  we  might  rest  pretty 
well  assured  that  the  bodies  were  not. 

In  the  case  related  by  Prout,  there  was  no  external  mark  of  injury 
over  the  point  of  fracture,  but  a  distinct  crepitus  was  perceptible  on 
pressure. 

Treatment. — If  the  fragments  are  not  displaced,  nothing  but  rest  and 
a  cooling  regimen  are  indicated;  but  if  they  are  forced  in  upon  the 
marrow,  an  important  question  is  presented,  and  which  has  received 
from  different  surgeons  different  solutions.  Shall  an  effort  be  made 
to  reduce  the  fragments?  and  if  so,  by  what  means  shall  the  indica- 
tion be  attempted  ? 

It  will  be  remembered  that  in  nearly  all  of  these  cases  we  must 
remain  in  doubt,  even  after  the  most  careful  examination,  as  to  the 
actual  condition  of  the  fracture.  It  may  be  that  what  we  suppose  to 
be  a  fracture  of  the  arch  is  only  a  fracture  of  the  apophysis,  or  that,  on 
the  other  hand,  it  is  a  fracture  of  the  body  of  the  bone  itself;  and  if  we 
are  expert  enough  to  make  out  clearly  a  fracture  of  the  arch,  it  is  not 
possible  for  us  to  say  that  the  body  is  not  broken  also,  indeed  it  is 
quite  probable  that  it  is  broken.     With  a  diagnosis  so  uncertain,  can 


148  FRACTUEES  OF  THE  VERTEBRA. 

we  ever  find  a  justification  for  surgical  interference?  Mr.  Cline  and 
Mr.  Cooper  thought  that  we  might.  According  to  them,  the  case  pre- 
sents in  no  other  direction  a  point  of  hope  or  encouragement.  Death 
is  inevitable,  sooner  or  later,  if  the  fragment  is  not  lifted,  and  we  can 
scarcely  make  the  matter  any  worse  by  interference.  If  it  proves  to 
be  a  fracture  of  the  apophysis,  as  happened  to  be  the  case  in  a  patient 
upon  whom  Sir  Astley  operated,'  our  interference  was  unnecessary, 
but  it  has  done  no  harm.  If  the  body  of  the  bone  is  broken,  the  ope- 
ration affords  no  resources,  but  the  patient  is  probably  beyond  suffering 
damage  at  our  hands.  If  the  diagnosis  is  correctly  made  out  and  the 
arch  only  is  broken,  and  if,  as  was  the  fact  in  the  case  of  Larkin  already 
mentioned,  there  is  no  bloody  effusion,  or  laceration  of  the  membranes 
or  of  the  marrow,  and  if  the  concussion  was  not  sufficient  to  deter- 
mine much  inflammation  of  the  cord,  then  it  would  seem  possible  that 
an  operation  might  save  the  patient. 

Paulus  ^gineta  first  suggested  that  the  compressing  fragments 
ought  to  be  removed  by  excision;  and  in  1762  Louis  removed  from 
a  man  who  had  received  a  gunshot  wound  in  his  back,  after  the  lapse 
of  five  days,  several  loose  pieces  of  bone  belonging  to  the  arch  of  the 
vertebra,  and  the  patient  recovered,  but  not  without  a  partial  para- 
lysis of  his  lower  extremities.  Of  course  nothing  could  be  more  ra- 
tional or  simple  than  this  procedure,  adopted  by  Louis,  in  any  case  of 
an  open  wound,  wherethe  fragments  could  be  easily  reached ;  but  the 
younger  Cline  was  the  first,  in  the  year  1814,  to  put  into  practice  the 
more  ancient  suggestion  of  Paulus  ^gineta,  namely,  to  attempt  the 
removal  of  the  fragments  in  a  case  of  simple  fracture.  He  made  an 
incision  upon  the  depressed  bones  as  the  patient  was  lying  upon  his 
face,  raised  the  muscles  covering  the  spinal  arch,  removing,  by  means 
of  a  circular  saw,  chisel,  mallet,  and  trephine,  &c.,  the  spinous  processes 
of  the  eleventh  and  twelfth  dorsal  vertebrae,  and  the  arch  of  one  of  the 
vertebrie.  The  patient  was  in  no  manner  relieved,  and  died  on  the 
fourth  day  after  the  receipt  of  the  injury  and  the  third  after  the  opera- 
tion.^ Mr.  Oldknow  repeated  this  operation  in  1819  in  a  case  of 
fracture  of  the  arch  of  the  seventh  vertebra.  The  patient  died  on  the 
sixth  day .3  In  1822,  Mr.  Tyrrell  operated  at  St.  Thomas's  Hospital  on  a 
man  who  had  been  injured  four  days  previously,  removing  the  spinous 
processes  of  the  twelfth  dorsal  and  first  lumbar  vertebra.  The  opera- 
tion was  accomplished  with  considerable  difficulty,  and  resulted  in 
only  a  partial  return  of  sensibility.  He  died  on  the  thirteenth  day  after 
the  operation."  In  1827,  Tyrrell  operated  a  second  time,  and  death 
resulted  on  the  eighth  day.^  On  the  30th  of  August,  1824,  Dr.  J. 
Ehea  Barton,  of  Philadelphia,  operated  upon  a  man  who  had  been 
received  into  the  Pennsylvania  Hospital  twelve  days  before,  with  a 
fracture  of  the  arch  of  the  seventh  dorsal  vertebra.  On  the  third  day 
he  was  attacked  with  a  violent  chill,  and  death  took  place  twelve  hours 

'  Clielius's  Surgery,  Amer.  ed.,  note  by  South,  vol.  i.  p.  592. 

^  Cline,  Chelius's  Surgery,  Amer.  ed.,  vol.  i.  p.  590. 

3  Sir  A.  Cooper  on  Disloc.  and  Frac,  Amer.  ed.,  1851,  p.  479. 

*  Sir  A.  Cooper's  Loc,  by  Tyrrell,  3d  Amer.  ed.,  1831,  vol.  ii.  p.  17. 

5  Med.-Cliir.  Rev.,  vol.  x.  p.  601. 


FRACTURES  OF  THE  VERTEBRAL  ARCHES.      149 

after.  The  dissection  showed  about  half  a  gallon  of  blood  in  the 
posterior  mediasiinum,  and  bloody  effusion  existed  along  the  whole 
length  of  the  spinal  canal.^  The  patient  whom  Laugier  trephined  at 
the  base  of  the  spinous  process  of  the  ninth  dorsal  vertebra,  died  on 
the  fourth  day.^  The  operation  has  been  repeated  unsuccessfully  by 
Wickham,  Attenburrow,  Holscher,  Heine,  and  Roux.' 

February  5th,  1834,  Dr.  David  L.  Eogers,  of  New  York,  operated 
upon  a  man  who  had  fallen  two  days  before,  breaking  the  arch  of  the 
first  lumbar  vertebra,  and  forcing  the  spinous  process  upon  the  cord. 
This  man  died  on  the  eighth  day.^ 

In  1854,  Dr.  Blackman,  of  Cincinnati,  operated,  his  patient  dying 
on  the  fourth  day.  During  the  same  year  also.  Dr.  B.  removed  a  por- 
tion of  the  sacrum  for  an  injury  of  four  years'  standing,  with  no 
benefit.^  In  1858,  Dr.  Stephen  Smith,  of  Bellevue,  removed  the  arch  of 
the  tenth  dorsal  vertebra,  death  occurring  soon  after.^  December  29th, 
1857,  ten  days  after  the  receipt  of  the  injury.  Dr.  J.  C.  Hutchinson, 
of  Brooklyn,  operated  upon  a  man  at  the  City  Hospital,  Brooklyn, 
removing  the  spinous  processes  of  the  eighth,  ninth,  and  tenth  dorsal 
vertebree,  with  the  posterior  arch  of  the  latter.  The  patient  survived 
the  operation  ten  days.^  Ballingall  says,  a  Dr.  Blair  has  operated 
successfully,  but  no  particulars  are  given. 

Dr.  H.  A.  Potter,  of  Geneva,  N.  Y.,  informs  us  that  he  has  operated 
three  times.  In  the  first  case  he  states  that  he  removed  the  posterior 
portion  of  the  three  lower  cervical  vertebrae.  The  patient  died  on  the 
fourth  day.  In  the  second  case  the  doctor  removed  the  spinous  pro- 
cesses of  the  fifth  and.  sixth  cervical  vertebrae,  and  the  entire  posterior 
arch  of  the  fifth.  The  sheath  was  not  broken,  "  but  the  cord  was  much 
injured."  There  was  almost  complete  paralysis  of  the  extremities, 
and  this  condition  was  not  remedied  by  the  operation.  Three  years 
later,  the  patient  being  still  alive,  but  only  a  very  slight  improvement 
having  taken  place.  Dr.  Potter  "  removed  the  fourth,  sixth,  and  seventh 
cervical  vertebraB."  (We  presume  he  intends  to  say  the  "  posterior 
arches.")  At  the  time  of  the  report,  Jan.  1863,  there  was  no  further 
improvement.  Finally,  the  doctor  reports  a  completely  successful 
case.  The  injury  was  of  "  five  months'  standing."*  Packard  says,  in 
a  note  to  his  translation  of  Malgaigne,  that  Dr.  Potter  operated  on  a 
case  of  three  months'  standing,  and  the  patient  died  on  the  eighteenth 
day.     I  suppose  this  to  be  the  same  case. 

These  are  all  of  the  cases  of  which  we  have  any  information  in 
which  this  operation  has  been  made,  and  they  have  all,  excepting  the 
two  cases  reported  by  Potter  and  the  one  by  Blair,  terminated  fatally 

'  Barton,  Godman's  ed.  of  Sir  A.  Cooper  on  Disloc,  &c.,  p.  421. 

2  Malgaigne,  Amer.  ed.,  p.  341. 

3  Chelius's  Surgery,  Amer.  ed.,  vol.  i.  p.  590.  Also,  Velpeau's  Op.  Surgery,  1st 
Amer.  ed.,  vol.  ii.  p.  737. 

*  Rogers,  Amer.  Journ.  Med.  Sci.,  May,  1835. 

5  Velpeau's  Surgery,  Blackmau's  ed.,  vol.  ii.  p.  892;  also,  Dr.  Ilutcbinson's 
Paper,  Trans.  N.  Y.  St.  Med.  Soc,  1861. 

6  New  York  Journ.  Med.,  1859,  p.  87. 

^  Hutchinson,  Trans.  N.  Y.  Med.  Soc,  1861.  p.  93. 
s  Amer.  Med.  Times,  Jan.  10,  1863. 


150  FRACTUKES  OF  THE  VERTEBRA. 

in  a  very  few  days.  The  case  reported  by  Alban  G.  Smith,  of 
Kentuck}^  is  not  related  in  such  a  manner  as  to  enable  us  to  make 
use  of  it  safely,  nor  is  it  stated  how  long  the  patient  survived  the 
operation  ;  Gibson  says  it  gave  no  permanent  relief.  The  example 
mentioned  by  an  English  writer  is  equally  unreliable,  inasmuch  as  it 
is  given  only  upon  rumor,  and  but  a  "few  months"  had  elapsed  since 
the  operation  was  performed.  It  was  said  to  have  been  made  in  the 
year  1838,  by  a  surgeon  of  the  name  of  Edwards,  in  South  Wales; 
and  it  was  affirmed  that  the  compression  was  relieved  and  that  the 
patient  "did  well."^  So  unique  a  case  would  certainly  have  found 
before  this  an  ample  confirmation.  Indeed,  we  must  say  that  none  of 
the  cases  reported  as  successful  give  any  evidence  of  authenticity. 

Experience,  then,  seems  to  have  shown  that  we  have  little  or  nothing 
to  expect  from  this  surgical  expedient;  and,  notwithstanding  the 
strong  hope  expressed  by  Sir  Astley  that  Mr.  Cline's  operation  might 
hereafter  prove  a  valuable  resource,  and  contrary  to  the  conclusions 
which  we  in  common  with  many  other  surgeons  had  drawn  from  the 
anatomical  relations  of  these  parts,  we  are  compelled  reluctantly  to 
declare  that  the  expedient  is  scarcely  worthy  of  a  trial.  To  the  same 
conclusion  also  many  of  the  most  distinguished  surgeons  have  arrived; 
among  whom  we  may  mention,  as  especially  entitled  to  confidence, 
Brodie,  Liston,  Alexander  Shaw,  Malgaigne,  and  Gibson. 

What  more  can  be  said  of  the  attempt  to  raise  the  depressed  bone 
by  seizing  the  spinous  process  with  the  fingers,  or  with  a  pair  of  strong 
hooked  forceps  passed  through  the  skin,  or  finally,  if  this  cannot  be 
done,  by  laying  bare  both  sides  of  the  process  and  seizing  upon  it 
with  a  pair  of  firm  tenacula  ?  This  is  the  alternative  presented  to 
Malgaigne,  and  which  he  ventures  to  recommend  as  deserving  a  trial. 
In  the  absence,  however,  of  any  testimony  in  its  favor,  beyond  the 
mere  rational  argument  adduced  by  this  distinguished  writer,  we  must 
waive  any  farther  consideration  of  the  subject;  only  expressing  our 
conviction  that  it  will  be  found,  after  a  fair  trial,  as  useless  and  as 
inexpedient  as  the  more  severe  operation  of  Cline. 

Jeffries  Wyraan,  of  Boston,  has  met  with  eleven  examples  of  frac- 
tures of  the  vertebral  arches  occurring  in  the  fourth  or  fifth  lumbar 
vertebrae  between  the  lower  articulating  and  the  transverse  processes, 
all  of  them  old,  ununited  fractures.  He  has  also  met  with  the  same 
fracture  once  in  the  third  lumbar  vertebra.  The  frequency  of  this 
peculiar  form  of  fracture  in  this  region  Dr.  Wyman  ascribes  to  the 
fact  that  the  upper  and  lower  articulating  processes  are  widely  sepa- 
rated from  each  other,  and  connected  only  by  a  narrow  neck,  in  which 
respect  they  contrast  very  strongly  with  the  dorsal  vertebras;  and  he 
supposes  that  the  fractures  may  be  caused  by  either  a  forcible  bend- 
ing of  the  body  backwards,  or  by  the  shock  resulting  from  a  fall  from 
a  height  in  which  the  force  of  the  concussion  is  conveyed  downwards 
through  the  pelvis.  In  no  case  has  the  existence  of  this  fracture  been 
recognized  during  life,  nor  is  it  probable  that  its  occurrence  would 

'  Edwards,  British  and  Foreign  Med.  Eev.,  1838,  p.  162. 


FRACTUEES    OF    THE    BODIES    OF    THE    VERTEBRAE.      151 

cause  any  marked  symptoms  unless  it  had  been  caused  by  a  blow  re- 
ceived directly  from  behind.' 

As  to  the  therapeutical  treatment  of  the  various  symptoms  belong- 
ing to  these  accidents,  and  in  relation  to  the  prognosis,  the  remarks 
which  we  shall  make  will  be  found  equally  applicable  to  fractures  of 
the  bodies  of  the  vertebrae,  and  we  shall  reserve  the  consideration  of 
these  topics  for  the  following  section. 

§  4.  Fractures  of  the  Bodies  of  the  YERTEBRiE. 

The  same  causes  which  produce  fractures  of  the  arches  may  produce 
also  fractures  of  the  bodies  of  the  vertebrae,  that  is,  blows  received 
directly  upon  the  extremities  of  the  spinous  processes ;  but  in  these 
cases  the  arches  are  generally  broken  at  the  same  time. 

In  other  cases  the  bodies  of  the  vertebrse  are  broken  by  falls  upon 
the  top  of  the  head,  by  which  the  vertebrae  are  not  only  driven  forci- 
bly together,  but  often  doubled  forwards  upon  each  other;  or  the 
patient  may  have  alighted  upon  his  feet  or  upon  his  sacrum. 

Eeveillon  has  reported  a  case  of  fracture  of  the  fifth  cervical  verte- 
bra from  muscular  action,  which  occurred  in  diving.  The  man  was 
taken  out  of  the  water  unconscious,  and  died  in  a  few  hours,  having 
declared  before  death  that  his  head  did  not  strike  the  bottom,  although 
he  had  jumped  from  a  height  of  seven  or  eight  feet,  and  the  water 
was  only  three  feet  deep.^  The  statement  of  the  sufferer,  under  such 
circumstances,  could  not  really  possess  much  value,  and  we  think  we 
see  good  reasons  to  suppose  that  he  was  mistaken.  South  also  relates 
a  case  of  fracture  of  the  fourth  and  fifth  cervical  vertebrae  occasioned 
by  diving,  in  which  it  was  supposed  that  the  fracture  was  caused  by 
the  concussion  of  the  head  upon  the  water.^ 

Malgaigne  says  the  spine  bends  at  three  principal  points  ;  comprised, 
the  first  between  the  third  and  seventh  cervical  vertebrae,  the  second 
between  the  eleventh  dorsal  and  second  lumbar,  the  third  between  the 
fourth  lumbar  and  the  sacrum  ;  and  that  a  majority  of  the  fractures  of 
the  vertebrae  occur  at  these  points  of  flexion.  He  makes  an  argument 
from  this  also  that  these  fractures  "  are  generally  the  result  of  counter- 
strokes  as  the  effect  of  forcible  flexion  of  the  column  either  forwards 
or  backwards."  Malgaigne  observes,  moreover,  that  dislocations  follow 
the  same  rule. 

The  direction  of  the  line  of  fracture  varies  greatly  in  the  different 
examples  which  we  have  seen ;  some  are  crushed,  and  more  or  less 
comminuted.  In  some  cases  a  narrow  piece  is  chipped  from  the  mar- 
gin, others  are  broken  transversely,  and  others  obliquely.  In  oblique 
fractures  the  line  of  the  fracture  is  generally  from  behind  forwards 
and  from  above  downwards.  Malgaigne  thinks  that  a  crushing  or 
comminution  can  only  occur  from  a  forcible  flexion  forwards ;  but  I 
have  seen  at  least  one  example  in  which  this  was  not  the  fact ;  the 

'  Wyman,  Boston  Med.  and  Surg.  Jonrn.,  Aug.  12,  1869. 

2  Reveillon,  Chelius's  Surg.,  note  by  South,  vol.  i.  p.  58-1. 

3  South,  ibid.,  p.  583. 


152 


FRACTURES  OF  THE  VERTEBRA. 


Fio:  34. 


patient  haviug  fallen  so  as  to  strike  with  the  back  of  his  neck  upon 
an  iron  bar.  This  was  the  case  of  the  sailor,  to  which  I  shall  again 
refer  more  particularly. 

The  upper  fragment  is  almost  always  that  which  suffers  displace- 
ment; sometimes  being  simply  driven  downwards,  and  thus  made  to 
penetrate  more  or  less  the  lower  fragment;  at  other  times,  as  in  cer- 
tain transverse  fractures,  it  is  only  displaced  forwards,  and  in  still 
other  examples,  where  the  fracture  is  oblique,  the  upper  fragment  is 
displaced  both  downwards  and  forwards. 

In  the  first  and  last  of  these  examples  the  spine  becomes  bent  for- 
wards at  the  point  of  fracture,  producing  an  angle  of  which  the  most 
salient  point  posteriorly  is  represented  by  the 
extremity  of  the  spinous  process  belonging 
to  the  broken  vertebra;  in  the  second  example 
the  spinous  process  of  the  broken  vertebra  is 
depressed,  and  the  process  of  the  vertebra 
next  below  is  relatively  prominent. 

Tn  a  pretty  large  proportion  of  cases  also 
the  fracture  of  the  body  of  the  vertebra  is 
complicated,  as  we  have  already  stated,  with 
a  fracture  of  the  arches,  in  some  instances 
with  a  fracture  of  the  oblique  processes,  and 
with  a  dislocation. 

Symptoms. — Severe  pain  at  the  seat  of  frac- 
ture, felt  especially  when  the  part  is  touched 
or  the  body  is  moved,  tenderness,  swelling, 
ecchymosis,  occasionally  crepitus,  a  slight 
angular  distortion  of  the  spine,  or  simply  a 
trifling  irregularity  in  the  position  of  the  pro- 
cesses, and  paralysis  of  all  the  parts  whose  nerves  take  their  origin 
below  the  fracture,  are  the  usual  signs  of  the  accident. 

The  paralysis  may  be  due  to  the  mere  pressure  of  the  displaced 
fragments,  but  it  is  much  more  often  due  to  a  severe  and  irreparable 
lesion  of  the  cord  itself.  I  have,  in  one  instance,  seen  the  cord  almost 
completely  separated  at  the  point  of  fracture,  although  the  displace- 
ment of  the  fragments  was  inconsiderable. 

Accom.panying  the  paralysis  of  the  bladder,  there  has  been  generally 
observed  an  alkaline  state  of  the  urine,  and  subacute  inflammation  of 
the  coats  of  the  bladder.  Priapism  is  present  in  a  certain  proportion 
of  cases. 

Those  who  die  immediately  seem  to  be  asphyxiated;  while  those 
who  die  later  seem  to  wear  out  from  general  irritation,  this  condition 
being  frequently  accompanied  with  an  obstinate  diarrhoea  and  vomit- 
ing.    A  few  become  comatose  before  death. 

It  will  be  seen,  moreover,  that  a  certain  proportion  finally  recover; 
but  scarcely  ever  are  all  the  functions  of  the  limbs  and  of  the  body 
completely  restored. 

We  shall  render  this  part  of  our  description  of  these  accidents  more 
intelligible  if  we  regard  them  as  they  occur  in  the  various  portions  of 


Oblique  fracture  of  the  body 
of  a  vertebra. 


FKACTURES    OF    THE    BODIES    OF    THE    VEETEBR^.      153 

the  spinal  column,  since  the  symptoms,  prognosis,  and  treatment  have 
reference  mainly  to  the  point  at  which  the  fracture  has  occurred. 

1.  Fracture  of  the  Bodies  of  the  Lumbar  Vertebrae. 

The  spinal  cord  terminates,  in  the  adult,  at  the  lower  border  of  the 
first  lumbar  vertebra,  but  in  the  child  at  birth  it  extends  as  low  as 
the  third  lumbar  vertebra.  The  remainder  of  the  vertebral  canal  is 
occupied  by  the  leash  of  terminal  nerves,  called  collectively  the  cauda 
equina. 

The  nerves  which  emerge  from  the  intervertebral  foramina  below 
the  fourth  and  fifth  lumbar  vertebrae,  unite  with  the  sacral  nerves  to 
form  a  plexus  which  supplies  the  sphincter  and  levator  ani,  the  peri- 
neal muscles,  the  detrusor  and  accelerator  urina3,  the  urethra,  the 
glans  penis,  and  a  great  proportion  of  the  lower  extremities.  It  will 
be  apparent,  therefore,  that  a  fracture,  with  displacement,  of  even  the 
last  vertebra  of  the  column,  involves  the  possibility  of  more  or  less 
paralysis  of  all  those  parts  supplied  by  this  plexus,  and  that  in  pro- 
portion as  the  fracture  is  higher  in  the  vertebral  column,  will  the  pro- 
bability of  additional  complications  be  increased.  In  other  words,  in 
addition  to  the  more  or  less  complete  loss  of  function  in  the  organs, 
supplied  by  the  ilio-sacral  plexus,  there  will  probably  be  associated 
loss  of  function  in  other  organs,  supplied  from  sources  above  this 
point  of  the  vertebral  canal. 

A  fracture,  however,  of  the  bodies  of  the  fourth  or  fifth  lumbar 
vertebra,  produced  by  a  direct  blow,  is  exceedingly  rare,  owing  to 
the  protection  which  it  receives  from  the  alee  of  the  pelvis. 

Dr.  Alexander  Shaw  has  reported  four  cases  of  fracture  below  the 
second  lumbar  vertebra,  which  were  unaccompanied  with  any  degree 
of  paralysis,  and  which  were  followed  by  speedy  recovery,^  a  circum- 
stance which  he  ascribes  to  the  fact  that  the  cauda  equina  is  composed 
of  nerves  possessing  considerable  firmness,  and  suspended  loosely 
together;  for  this  reason  they  escape  pressure  by  slipping  among 
themselves,  and  suffer  less  injury  from  the  same  amount  of  compression 
than  the  medulla  spinalis. 

In  the  two  following  cases  the  results  were  less  fortunate,  yet  reco- 
veries seem  to  have  taken  place. 

A  boy  was  admitted  into  St.  George's  Hospital,  in  Sept.  1827,  with 
a  fracture  and  considerable  displacement  of  the  third  and  fourth  lum- 
bar vertebrae,  the  displacement  being  sufficient  to  cause  a  manifest 
alteration  in  the  figure  of  his  spine.  His  lower  limbs  were  paral3^tic. 
An  attempt  was  made  to  restore  the  displaced  vertebrae,  but  it  was 
attended  with  only  partial  success.  At  the  end  of  a  month  he  had 
slight  involuntary  motions  of  the  lower  extremities,  and  at  the  same 
time  he  began  to  recover  the  power  of  using  them  voluntarily.  Three 
or  four  months  after  the  receipt  of  the  injury  he  left  the  hospital,  and 
,the  history  of  his  case  was  interrupted  at  this  date.^ 

Dr.  Thompson,  of  Goshen,  N.  Y.,  reports,  also,  a  fracture  of  either 

'  Shaw,  London  Med.  Gaz.,  vol.  xvii. 
2  Brodie.     Sir  Ast.  Cooper  on.  Disloc,  op.  cit.,  p.  471. 
11 


154 


FRACTURES  OF  THE  VERTEBRA. 


Key's  case  of  fracture  of  the 
&rBt  lum'bdr  vertebra. 


the  third  or  fourth  lumbar  vertebra,  followed  by  recovery.  The 
patient  fell  from  the  roof  of  a  house,  striking  first  upon  his  feet  and 
then  upon  his  buttocks.  This  occurred  in  October,  1853.  The  usual 
signs  of  a  fracture  were  present,  such  as  paralysis,  &c.  A  bed-sore 
formed  above  the  top  of  the  sacrum,  and  a  piece  of  bone  exfoliated 
which  seemed  to  belong  to  the  last  lumbar  vertebra.  He  was  con- 
fined to  his  bed  seven  months.  After  eighteen  months  he  began  to 
use  crutches.  At  the  end  of  about  three  years 
all  improvement  ceased ;  at  which  time  he  could 
not  quite  stand  alone,  yet  with  the  aid  of  appa- 
ratus he  was  able  to  get  about  the  country  and 
vend  books,  prints,  &c.  This  was  also  his  con- 
ditioji  one  year  later.^ 

A  patient  in  Guy's  Hospital,  under  Mr.  Key, 
with  a  fracture  of  the  first  lumbar  vertebra, 
lived  one  year  and  two  days.  On  examination 
after  death  it  was  ascertained  that  bony  union 
had  occurred  between  the  fragments,  and  that 
the  spinal  marrow  was  completely  separated  at 
the  point  of  fracture.^ 

Mr.  Harrold  relates  a  case  of  fracture  of  the 
first  and  second  lumbar  vertebrae,  in  which  the 
patient  survived  the  accident  one  year  lacking 
nine  days;  death  having  resulted  finally  from 
a  sore  on  the  tuberosity  of  the  ischium  and 
disease  of  the  bone.  After  death  it  was  ascertained  that  the  fracture 
had  united  by  bone,  and  that  the  spinal  marrow  was  almost  com- 
pletely cut  in  two,  the  divided  extremities  being  enlarged  and  sepa- 
rated nearly  an  inch  from  each  other.^ 

2.  Fractures  of  the  Bodies  of  the  Dorsal  Vertebrae. 

In  these  examples  the  same  organs  are  paralyzed  as  in  the  fractures 
lower  down,  in  addition  to  which  there  is  generally  considerable  dis- 
turbance of  the  functions  of  respiration,  irregular  action  of  the  heart, 
indigestion  accompanied  with  a  tympanitic  state  of  the  bowels. 

Dupuytren,  who  reports  several  examples  of  fractures  of  the  dorsal 
-vertebras,  has  not  taken  the  pains  to  record  the  length  of  time  they 
survived  the  accident  except  in  two  instances,  both  of  which  were 
fractures  of  the  eleventh  vertebra.  One  died  of  suffocation  on  the 
tenth  day,  and  the  other  on  the  thirty-second.  In  Sir  Astley  Cooper's 
cases,  mention  is  made  of  a  fracture  of  the  twelfth  dorsal  vertebra, 
-which  the  patient  survived  fifty-two  days,  one  of  the  tenth  dorsal, 
which  terminated  fatally  in  six  days,  and  another  of  the  ninth  dorsal, 
w'hich  did  not  result  in  death  until  after  nine  weeks. 

In  1853  Dr.  Parkman  presented  to  the  Boston  Society  for  Medical 
Improvement  a  specimen  of  fracture  of  the  fifth  dorsal  vertebra,  the 

»  Thompson,  Amer.  Joum.  Med.  Sci.,  Oct.  1857.     Lente's  paper. 
2  Key,  A..  Cooper  on  Disloc,  &c.,  op.  cit.,  p.  467. 
«  Harrold,  A.  Cooper,  op.  cit.,  p.  464. 


FRACTURES  OF  THE  BODIES  OF  THE  VERTEBRA,   155 

bodies  of  the  third  and  fourth  being  also  displaced  forwards,  in  which 
position  they  had  become  firmly  ossified.  The  spinal  cord  had  been  com- 
pletely separated,  yet  the  patient  survived  the  accident  two  months.' 
Dupuytren  has  related  also  two  examples  of  fractures,  one  of  the 
tenth  and  the  other  of  the  last  dorsal  vertebra,  from  which  the  patients 
completely  recovered  after  from  two  to  four  months'  confinement.^  A 
similar  case  is  related  by  Lente,  of  New  York.  Barney  McGuire, 
having  fallen  a  distance  of  twelve  or  fifteen  feet  upon  his  back,  was 
found  with  nearly  complete  paralysis  of  his  lower  extremities,  and  of 
his  bladder.  Swelling  existed  over  the  lower  dorsal  vertebrae,  and 
this  point  was  very  tender.  Subsequently,  when  the  swelling  subsided, 
the  prominence  of  the  spinous  processes  of  the  tenth  and  eleventh 
dorsal  vertebrae  put  the  question  of  a  fracture  beyond  doubt.  Gradu- 
ally, under  the  use  of  cups,  strychnia,  mineral  acids,  laxatives,  buchu, 
and  electricity,  his  symptoms  improved.  In  six  months  he  was  able 
to  walk  about  the  streets,  and  four  years  after  the  accident  he  was 
employed  in  a  foundry  under  regular  wages,  being  able  to  stand  fif- 
teen or  twenty  minutes  at  a  time,  and  to  walk  half  a  mile  without 
resting.  At  this  time  there  remained  no  tenderness  in  the  spine,  but 
the  projection  of  the  process  was  the  same  as  at  first.' 

3.  Fractures  of  the  Bodies  of  the  five  lower  Cervical  Vertebrae. 

We  shall  now  have  added  to  the  symptoms  already  enumerated, 
paralysis  of  the  upper  extremities,  greater  embarrassment  of  the  res- 
piration, and  more  complete  loss  of  sensation  and  volition  in  the  lower 
part  of  the  body.  In  general,  also,  the  eyes  and  face  look  congested, 
owing  to  the  imperfect  arterialization  of  the  blood,  and  death  is  more 
speedy  and  inevitable. 

In  ten  recorded  examples  of  fractures  of  the  five  lower  cervical 
vertebrae  which  I  have  been  able  to  collect,  one  died  within  twenty- 
four  hours,  four  in  about  forty-eight  hours,  one  in  eleven  days,  one 
lived  fifteen  weeks  and  six  days,  one  about  four  months,  one  fifteen 
months,  and  one,  reported  by  Ililton,  survived  fourteen  years.*  The 
most  common  period  of  death  seems  therefore  to  be  about  forty-eight 
hours  after  the  receipt  of  the  injury. 

The  example  of  the  patient  who  survived  the  accident  fifteen  weeks 
and  six  days,  is  recorded  by  Mr.  Greenwood,  of  England.  A  woman, 
Mary  Vincent,  set.  47,  was  injured  by  a  blow  on  the  back  of  her  neck, 
but  she  was  not  seen  by  Mr.  Greenwood  until  after  eleven  days,  at 
which  time  she  was  breathing  with  dif&culty,  occasioned  by  paralysis 
of  the  intercostal  muscles,  respiration  being  carried  on  by  the  dia- 
phragm and  abdominal  muscles  alone.  This  was  the  extent  of  the 
paralysis.  There  seemed  to  be  a  depression  opposite  the  fourth  and 
fifth  cervical  vertebrae,  and  pressure  at  this  point  occasioned  universal 
paralysis,  as  did  also  the  action  of  coughing  and  sneezing.     About 

'  Parkman,  New  York  Journ.  Med.,  March,  1853,  p.  386. 

2  Dupuytren,  op.  cit.,  pp.  356-7. 

3  Lente,  Amer.  Journ.  Med.  Sci.,  Oct.  1857,  p.  361. 
*  Hilton,  Lend.  Lancet,  Oct.  27,  1860. 


156  FRACTURES  OF  THE  VERTEBRA. 

three  weeks  after  the  accident,  she  attempted  for  the  first  time  to  move, 
in  order  to  have  her  clothes  changed,  when  she  was  immediately  seized 
with  paralysis  in  the  right  arm  and  hand.  After  this  she  lost  her  appe- 
tite, had  frequent  attacks  of  purging,  and  thus  she  gradually  wore  out.* 

The  patient  who  survived  about  four  months  was  admitted  into 
Hotel  Dieu,  under  the  care  of  Dupuytren,  in  1825,  On  account  of  a 
fracture  of  the  fourth  cervical  vertebra,  caused  by  a  fall  on  the  back 
of  his  neck,  and  suffering  under  paralysis  of  the  bladder  and  extremi- 
ties. After  two  months  and  a  half  of  entire  rest,  he  was  convalescent 
and  quitted  the  hospital,  with  only  slight  weakness  in  his  left  leg,  and 
with  his  head  a  little  bowed  forwards.  In  returning  from  a  long  walk 
he  fell  paralyzed,  and  remained  in  the  open  air  all  night.  From  this 
time  he  continued  to  fail,  and  died  thirty-four  days  after  the  second 
fall.  On  examination  after  death,  the  bodj'-  of  the  vertebra  was 
found  to  be  broken,  and  also  the  processes  of  the  fifth,  allowing  the 
fourth  to  slip  forwards  and  compress  the  cord.  A  true  callus  existed 
in  front  of  these  bones,  which  looked  as  if  recently  broken.  The  cord 
itself  exhibited  an  annular  constriction,  which  Dupuytren  conceived 
to  be  the  seat  of  the  original  lesion  narrowed  by  cicatrization.^ 

The  following  example  furnishes  a  fair  illustration  of  the  usual 
phenomena  which  accompany  fractures  of  the  third  or  fourth  cervical 
vertebra. 

On  the  25th  of  July,  1857,  a  sailor  fell  backwards  from  the  wharf, 
striking  with  the  nape  of  his  neck  upon  a  bar  of  iron.  I  saw  him  on 
the  following  day,  in  consultation  with  his  attending  physician,  Dr. 
Edwards.  He  was  lying  upon  his  back,  breathing  rapidly.  His 
lower  extremities  were  completely  paralyzed ;  legs  and  feet  swollen 
and  purple;  right  arm  completely  paralyzed,  and  his  left  partially; 
from  a  point  below  the  line  of  the  second  rib,  there  was  no  sensation 
whatever ;  his  bowels  had  not  moved,  although  he  had  already  taken 
active  cathartics;  the  urine  had  been  drawn  with  a  catheter;  the  pulse 
was  slower  than  natural,  and  irregular.  He  was  constantly  vomiting. 
In  reply  to  questions,  he  said  that  he  felt  well,  articulating  distinctly 
and  with  a  good  voice.  His  eyes  and  face  were  somewhat  congested, 
but  with  this  exception  his  countenance  did  not  betray  the  least  phy- 
sical disturbance.  He  lived  in  this  condition  about  forty  hours,  only 
breathing  shorter  and  shorter,  and  his  consciousness  remaining  to  the 
last  moment. 

In  proceeding  to  examine  the  spine  a  few  hours  after  death,  and 
before  any  incision  was  made,  we  were  unable,  upon  the  most  minute 
examination,  to  detect  any  irregularity  of  the  processes  of  the  cervi- 
cal vertebrae,  or  any  crepitus ;  but,  on  dissecting  the  neck,  we  found 
that  the  arches  of  the  third  and  fourth  vertebrae  were  broken,  and 
the  spinous  processes  slightly  depressed  upon  the  cord.  The  bodies 
of  the  corresponding  vertebrae  were  comminuted,  and  the  vertebrae 
above  were  driven  down  upon  them,  carrying  the  processes  in  the  same 
direction.  The  theca  and  the  spinal  marrow  were  almost  completely 
severed  upon  a  level  with  the  fourth  vertebra. 

'  Greenwood,  Sir  A.  Cooper  on  Disloc,  p.  472. 
2   Dupuytren,  op.  cit.,  p.  358. 


FRACTURES  OF  THE  BODIES  OF  THE  VERTEBRA.   157 

A  man  residing  in  Erie  Co.,  N.  Y.,  was  thrown  backwards  suddenly 
from  the  back  end  of  a  wagon,  alighting  upon  the  top  of  his  head. 
Dr.  Mixer  having  requested  me  to  see  this  patient  with  him,  I  found 
the  symptoms  almost  an  exact  counterpart  of  those  which  belonged 
to  the  case  which  I  have  just  described,  except  that  a  crepitus  and  a 
mobility  of  the  fragments  could  be  distinctly  felt  in  the  upper  and 
back  part  of  his  neck.  His  death  occurred  in  very  much  the  same 
manner  after  about  forty-eight  hours.  No  autopsy  was  allowed.  We 
noticed  in  this  case,  also,  that  whenever  he  was  turned  over  upon  his 
face,  respiration  almost  entirely  ceased,  but  it  was  immediately  re- 
stored by  laying  him  again  on  his  back.  Many  other  similar  exam- 
ples have  from  time  to  time  come  under  my  notice. 

Strains  of  the  Ligaments  and  Muscles. — Dupuytren,  Sir  Astley  Cooper, 
South,  and  other  surgeons  have  related  cases  simulating  fracture,  but 
which  proved  to  be  strains  of  the  ligaments  uniting  the  cervical  ver- 
tebrse,  accompanied  with  more  or  less  injury  to  the  spinal  marrow. 
In  one  instance,  I  have  met  with  what  has  seemed  to  be  a  strain  of 
the  ligaments  and  muscles  of  the  neck,  but  which  presented  no  symp- 
toms of  serious  injury  to  the  spinal  marrow. 

John  Neuman,  of  Canada  West.  set.  25,  fell  head  foremost  from  a 
height  of  fourteen  feet,  striking  upon  the  top  of  his  head.  He  was 
taken  up  insensible,  and  remained  in  this  condition  six  hours.  When 
consciousness  returned,  his  head  was  very  much  drawn  backwards, 
and  it  was  impossible  to  move  it  from  this  position.  There  was  no 
lack  of  sensibility,  or  of  the  power  of  motion  in  his  limbs,  and  all  the 
functions  of  his  body  were  in  their  natural  state;  but  he  has  suffered 
with  occasional  severe  pains  in  his  arms  ever  since.  The  accident 
happened  on  the  twenty-fourth  of  November,  1857,  and  he  called 
upon  me  eight  months  after.  His  head  was  then  forcibly  bent  for- 
wards instead  of  backwards,  into  which  position  it  had  gradually 
changed.  In  the  morning  he  generally  was  able  to  erect  his  head 
completely,  but  after  a  few  hours  it  was  constantly  drawn  forwards, 
as  when  I  saw  him.  There  was  no  tenderness  or  irregularity  over 
the  cervical  vertebrae,  and  he  was  so  well  as  to  be  regularly  employed 
as  a  day-laborer. 

Concussion. — Sir  Astley  Cooper  has  collected  four  examples  of  what 
he  terms  "concussion  of  the  sprinal  marrow,"  all  of  which  recovered 
after  periods  ranging  from  a  few  weeks  to  many  months ;  but  in  only 
one  case  is  it  stated  that  the  recovery  was  complete.^  Boyer  also 
enumerates  three  cases  of  concussion  which  came  under  his  own  ob- 
servation, all  of  which  terminated  fatally  in  a  short  time.  In  the  first 
example  mentioned  by  Boyer,  the  autopsy  disclosed  neither  lesion  nor 
effusion  of  any  kind  ;  in  the  second  case,  it  does  not  appear  that  any 
autopsy  was  made.  The  third  is  related  as  follows  :  "  A  builder  fell 
from  a  height  of  fourteen  feet,  and  remained  for  some  time  senseless; 
and,  on  recovering  from  that  situation,  found  that  he  had  lost  the  use 
of  his  inferior  extremities.  He  had  at  the  same  time  a  retention  of 
urine,  an  involuntary  discharge  of  the  feces,  and  some  disorder  in  the 

'  A.  Cooper,  op.  cit.,  p.  454. 


158  FEACTURES    OF    THE    VERTEBRAE. 

function  of  respiration.  Death  followed  on  the  twelfth  day  after  the 
accident.  The  body  was  opened,  and  the  vertebral  canal  was  found 
to  contain  a  sanguineous  serum,  the  quantity  of  which  was  sufficient 
to  fill  a  little  more  than  its  lower  half."^  No  doubt  some  of  the  cases 
reported  as  concussion  were  only  examples  of  paralysis  from  extrava- 
sation of  blood,  a  circumstance  which  is  peculiarly  likely  to  happen 
as  a  result  of  the  rupture  of  one  of  those  numerous  large  vessels 
which  surround  the  vertebrae  outside  of  the  thecse.  It  is  seldom  that 
the  vessels  of  the  cord  itself  give  out  sufficient  blood  in  these  cases 
to  cause  compression.  Possibly  examples  of  compression  as  a  re- 
sult of  extravasation  of  blood  may  sometimes  be  recognized  by  the 
fact  of  the  gradual  approach  of  the  paralysis  after  the  lapse  of  seve- 
ral hours,  as  has  occurred  recently  in  a  case  brought  to  my  notice  at 
the  Bellevue  Hospital,  and  in  which  recovery  finally  took  place. 

4.  Treatment  of  Fracture  of  the  Bodies  of  the  Vertebrae  when  the  fracture 
occurs  in  any  portion  of  the  column  below  the  Second  Cervical. 

In  a  few  instances,  I  have  noticed  among  the  recorded  examples  of 
fractures  of  the  bodies  of  the  vertebrre,  that  surgeons  have  made  some 
slight  attempt  to  reduce  the  fracture,  or  rather  to  rectify  the  spinal 
distortion,  generally  by  the  application  of  moderate  extension  to  the 
limbs,  and  by  laying  the  patient  horizontally  upon  a  hard  mattress. 
But  I  have  not  been  able  to  discover  that  in  any  case  the  patients  have 
derived  benefit  from  the  attempt,  although  it  has  been  said  occasionally, 
by  the  gentlemen  making  the  report,  that  the  deformity  was  slightly 
diminished.  Nor  am  I  aware  that  in  any  instance  the  patient  has  suf- 
fered any  damage  from  the  attempt ;  at  least  the  reporter  has  in  no 
case  thought  it  necessary  to  make  this  observation.  I  am  confident, 
however,  that  such  manipulation  can  seldom  serve  any  useful  purpose  ; 
and  I  very  much  fear  that  it  has  been  frequently  a  source  of  mischief. 
Although  in  cases  so  generally  fatal,  it  might  be  very  difficult  to  esti- 
mate with  much  accuracy  the  amount  of  injury  done.  If  by  any 
possibility  the  fragments  could  be  replaced,  I  know  of  no  means  by 
which  they  could  be  kept  in  place ;  and  in  truth  we  are  much  more 
likely  to  increase  the  penetration  of  the  spinal  cord  and  the  general 
disturbance,  than  to  diminish  it,  by  extension  or  pressure.  Moreover, 
it  usually  inflicts  upon  the  unfortunate  suft'erer  great  pain,  and  for 
these  reasons  it  ought  generally  to  be  discouraged, 

I  have,  however,  met  with  two  cases  of  fracture  of  the  lumbar  verte- 
brae, in  which  relief  was  afforded  by  permanent  extension.  When 
the  fracture  is  below  the  middle  of  the  vertebral  column,  extension,  if 
employed,  should  be  made  by  adhesive  straps,  weights,  and  a  pulley, 
as  will  hereafter  be  directed  in  fractures  of  the  femur ;  the  counter-ex- 
tension being  made  by  the  weight  of  the  body.  It  will  be  understood, 
however,  that  when  paralysis  exists  the  ligation  of  a  limb  with  band- 
ages will  expose  the  patient  to  great  danger  of  ulceration  and  sloughing 

•  Boyer,  Lecture  on  Diseases  of  the  Bones,  Amer.  ed.,  1805,  p.  55. 


FRACTURES    OF    THE    BODIES    OF    THE    VERTEBRA.      159 

at  and  below  tbe  points  of  pressure,  and  the  amount  of  extension  must 
be  very  moderate. 

When  treating  of  fractures  of  the  arches  of  the  vertebrae,  I  took 
occasion  to  call  attention  to  Mr.  Cline's  operation,  occasionally  recom- 
mended and  practised  in  such  cases.  I  was  not  ignorant,  however, 
that  Mr.  Cline  and  several  other  of  the  advocates  of  this  operation 
had  recommended  it  especially  for  fractures  of  the  bodies  of  the 
vertebrae  when  accompanied  with  displacement.  Even  Malgaigne 
has  preferred  to  consider  the  merits  of  this  operation  in  its  relations 
to  these  latter  fractures;  but  while  I  am  prepared  to  admit  the  pro- 
priety of  an  argument  as  to  the  value  of  Cline's  operation  considered 
in  reference  to  fractures  of  the  arches,  I  cannot  admit  its  propriety  in 
reference  to  fractures  of  the  bodies  of  the  vertebrae.  The  proposition 
appears  to  me  too  absurd  to  be  entertained  for  a  moment. 

The  treatment,  then,  ought  to  be,  in  a  great  measure,  expectant. 
The  patient  should  be  laid  in  such  a  position  as  he  finds  most  com- 
fortable, and,  as  far  as  possible,  the  spine  should  be  kept  at  rest,  since 
the  most  trivial  disturbance  of  the  fragments,  and  even  that  which 
may  cause  no  pain  to  the  patient,  is  liable  to  increase  the  injury  to 
the  spine,  and  prevent  the  formation  of  a  bony  callus.  Especially 
ought  the  surgeon  to  be  careful,  while  making  the  examination,  not  to 
turn  the  patient  upon  his  face,  in  which  position  the  spine  loses  its 
support  and  a  fatal  pressure  may  be  produced.  The  urine  should  be 
drawn  very  soon  after  the  accident,  and  at  least  twice  daily  for  the 
next  few  weeks.  Indeed,  it  is  a  better  rule  to  draw  the  urine  as  often 
as  its  accumulation  becomes  a  source  of  inconvenience,  or  whenever 
the  bladder  fills,  which  will  in  some  cases  be  as  often  as  every  four  or 
six  hours.  It  is  especially  necessary  to  attend  to  those  urgent  demands 
of  the  patient  during  the  first  few  weeks,  when  the  paralysis  is  most 
complete  generally,  and  the  mucous  surface  of  the  bladder,  already  irri- 
tated and  inflamed  by  the  excessively  alkaline  urine,  suffers  additional 
injury  from  any  degree  of  painful  distension  of  its  walls.  It  is  unneces- 
sary to  say  that  the  frequent  introduction  of  the  catheter  may  itself 
prove  a  source  of  irritation,  unless  it  is  managed  carefully  and  skilfully. 
This  duty  ought  never  to  be  intrusted  to  an  inexperienced  operator. 

I  do  not  see  what  advantage  the  surgeon  can  expect  to  derive  from 
the  administration  of  drastic  purgatives,  such  as  full  doses  of  jalap, 
castor  oil,  or  spirits  of  turpentine,  at  any  period.  If  in  the  first 
instance  the  bowels  are  so  completely  paralyzed  as  that  they  seem  to 
demand  such  violent  measures  to  arouse  them  to  action,  we  may  be 
quite  certain  that  the  spinal  cord  is  suffering  from  a  pressure,  or  from 
some  lesion,  which  these  agents  have  no  power  to  remedy.  The 
bowels  may  possibly  be  made  to  act,  but  it  would  be  difficult  to  show 
bow  this  is  to  relieve  the  suffering  cord.  So  far  from  affording  relief, 
these  measures  add  directly  to  the  nervous  irritation  and  prostration, 
provoke  vomiting  and  general  restlessness.  It  is  not  desirable,  we 
think,  to  obtain  a  movement  of  the  bowels  during  the  first  few  days 
by  any  means,  however  gentle.  The  effort  to  defecate,  and  the  conse- 
quent motion,  will  probably  do  much  more  harm  than  the  evacuation 
can  do  good ;  and  especially,  for  the  same  reason,  ought  we  to  avoid 


160  FRACTURES  OF  THE  VERTEBRA. 

putting  into  the  stomach  anything  which  will  occasion  nausea  and 
vomiting. 

After  the  lapse  of  a  few  days,  if  reasonable  hopes  begin  to  be  enter- 
tained of  a  recovery,  it  will  become  important  to  establish  regular 
evacuations  of  the  bowels,  either  by  a  judicious  management  of  the 
diet,  by  gentle  laxatives,  or  by  enemata.  At  a  still  later  period,  when 
the  inflammatory  stage  is  past,  and  the  nerves  remain  inactive  or  para- 
lyzed, nothing  could  be  more  rational  than  the  employment  of  strych- 
nia in  doses  varying  from  the  one-twelfth  to  the  one-eighth  of  a  grain 
three  times  daily.  Nor  do  I  think  that  any  single  remedy  has  more 
often  proved  useful  in  my  own  practice,  or  in  the  practice  of  other 
surgeons  with  whom  I  am  acquainted.  In  order,  however,  to  derive 
benefit  from  this  or  from  any  other  remedy,  it  must  be  continued  for 
a  long  time;  perhaps  for  a  year  or  more.  Electricity,  setons,  issues, 
and  blisters  are  no  doubt  also  sometimes  useful.  Care  must  be  taken 
that  setons,  &c.,  do  not  produce  bed-sores.  Passive  motion  and  fric- 
tions, good  fresh  air,  and  nourishing  diet,  become  at  last  essential  to 
recovery.  From  an  early  period,  and  during  the  whole  course  of  the 
treatment,  great  attention  should  be  paid  to  the  prevention  of  bed- 
sores, by  supporting  all  those  parts  of  the  body  upon  which  the 
pressure  is  considerable.  For  this  purpose  we  may  employ  circular 
cushions,  air-cushions,  and  air-beds ;  but  water-beds  are  very  much 
to  be  preferred  to  air-beds  as  a  means  of  preventing  bed-sores.  Water- 
beds  must  be  filled  with  water  of  the  temperature  of  68°  Fahrenheit, 
and  they  must  be  secured  in  position  by  side  boards,  or  a  kind  of 
shallow  box,  the  sides  of  which  are  elevated  six  or  seven  inches.  Perma- 
nent extension  can  be  employed  upon  these  beds  as  well  as  upon  ordinary 
beds.  Sometimes  a  section  of  a  bed,  three  feet  square,  is  found  quite 
as  serviceable  as  an  entire  bed,  inasmuch  as  the  back  and  nates  are  the 
only  parts  which  are  liable  to  bed-sores.  They  may  be  obtained  from 
the  manufacturers,  Hodgman  &  Co.,  corner  Nassau  St.  and  Maiden 
Lane,  New  York  city,  at  prices  ranging  from  $15  to  $25.  Of  late 
we  have  found  the  wire-beds,  manufactured  at  59  Pearl  St.,  Hartford, 
Conn.,  excellent  substitutes  for  water-beds.  They  are  less  expensive, 
more  easily  managed,  more  durable,  and  admit  of  a  much  better  regu- 
lation of  the  temperature.     Whether  they  are  quite  as  efficient  in  the 

Fiff.  36. 


Wire-bed. 


prevention  of  bed-sores  as  water-beds,  I  cannot  say  positively,  but 
they  have  been  much  used  under  my  observation  at  Bellevue  and  in 
the  Hospital  for  Ruptured  and  Cripples,  and  I  have  seen  no  bed-sores 
occur  where  they  were  in  use. 

When  sores  have  formed,  they  should  be  treated,  if  sloughing,  with 
yeast  poultices,  or  the  resin  ointment.     I  find  also  the  resin  ointment 


FEACTURES    OF    THE    AXIS.  161 

an  excellent  dressing  for  the  sores  after  the  sloughs  have  separated. 
In  case  the  surface  is  only  slightly  abraded,  simple  cerate  forms  the 
best  application. 

§  5.  Fractures  op  the  Axis. 

The  phrenic  nerve  is  derived  chiefly  from  the  third  and  fourth  cer- 
vical nerves.  If,  therefore,  the  second  cervical  vertebra  is  broken, 
and  considerably  depressed  upon  the  spinal  cord,  respiration  ceases 
immediately,  and  the  patient  dies  at  once,  or  survives  only  a  few 
minutes.  la  such  examples  of  fracture  of  this  bone  as  have  not  been 
attended  with  these  results,  the  displacement  and  consequent  compres- 
sion have  been  inconsiderable,  or  there  has  been  no  displacement  at  all. 

Mr.  Else,  of  St.  Thomas's  Hospital,  says  that  a  woman  in  the  vene- 
real ward,  and  who  was  then  under  a  mercurial  course,  while  sitting  in 
bed,  eating  her  dinner,  was  seen  to  fall  suddenly  forwards ;  and  the 
patients,  hastening  to  her,  found  that  she  was  dead.  Upon  examina- 
tion of  her  body,  it  was  discovered  that  the  processus  dentatus  of  the 
axis  was  broken  off,  and  that  the  head  in  falling  forwards  had  driven 
the  process  backwards  upon  the  spinal  marrow  so  as  to  cause  her  death.* 

Sir  Astley  also  relates  the  case  of  a  man  who  was  shot  by  a  pistol 
through  the  neck,  breaking  and  driving  in  upon  the  spinal  marrow 
both  the  "  lamina  and  the  transverse  process"  of  the  axis.  He  died 
on  the  fourth  day.^ 

Malgaigne  has  collected  three  cases  of  fracture  of  the  odontoid 
apophysis,  all  of  which  were  accompanied  with  a  displacement  of  the 
atlas.  The  first,  reported  by  Richet,  died  on  the  seventeenth  day ; 
the  second,  reported  by  Palletta,  died  after  one  month  and  six  days ; 
and  the  third,  by  Costes,  lived  four  months  and  two  weeks. 

Rokitansky  says  that  there  is  a  specimen  contained  in  the  Vienna 
Museum,  taken  from  a  patient  who  survived  the  accident  some  time, 
althouo-h  the  fragments  never  united. 

The  following  case  is  reported  by  Parker : — 

"  The  patient,  Mr.  G.  B.  Spencer,  was  a  man  forty  years  of  age,  a 
milkman  by  occupation,  of  medium  height,  nervo-sanguine  tempera- 
ment, of  active  business  habits,  and  capable  of  great  endurance.  His 
life  was  one  of  constant  excitement,  and  he  was  addicted  to  the  free 
use  of  liquors.  He  suffered,  however,  from  no  other  form  of  disease 
than  occasional  attacks  of  rheumatism,  for  which  he  was  accustomed 
to  take  remedies  of  his  own  prescribing,  which  were  generally  mer- 
curials followed  by  liberal  doses  of  iodide  of  potassium,  '  to  work  it 
all  out  of  the  system.' 

"  On  the  12th  of  August,  1852,  while  driving  a  '  fast  horse'  at  the 

*  t 

top  of  his  speed  on  the  plank  road  near  Bushwick,  L.  I.,  he  was  thrown 
violently  from  his  carriage  by  the  wheel  striking  against  the  toll-gate. 
He  alighted  upon  his  head  and  face  about  fifteen  feet  from  the  carriage. 
Upon  rising  to  his  feet  he  declared  himself  uninjured,  but  soon  after 

'  Else,  A.  Cooper  on  Disloc,  &c.,  op.  cit.,  p.  462. 
2  A.  Cooper  on  Disloc,  etc.,  op.  cit.,  p.  476. 


162  FRACTUEES  OF  THE  VERTEBRA. 

complained  of  feeling  faint;  after  drinking  a  glass  of  brandy  he  felt 
better,  got  into  his  carriage  with  a  friend,  and  drove  home  to  Riving- 
ton  Street  in  this  city,  a  distance  of  more  than  two  miles.  There  was 
so  little  apparent  danger  in  his  case,  that  no  physician  was  called  that 
night.  Early  on  the  morning  of  the  following  day.  Dr.  B.  was  called 
to  visit  him.  He  found  his  patient  reclining  in  his  chair,  in  a  restless 
state,  and  learned  that  he  had  suffered  considerable  pain  in  the  back 
part  of  his  head  and  neck  during  the  night.  He  was  entirely  incapaci- 
tated to  rotate  the  head,  which  led  to  the  suspicion  of  some  injury  to 
the  articulations  of  the  upper  cervical  vertebras ;  but  so  great  a  degree 
of  swelling  existed  about  the  neck  as  to  prevent  efficient  examina- 
tion. There  was  no  paralysis  of  any  portion  of  the  body,  his  pulse 
was  about  90,  and  his  general  system  but  little  disturbed.  Warm 
fomentations  were  applied  to  the  neck,  and  a  mild  cathartic  adminis- 
tered. On  the  following  day  there  was  no  particular  change  in  his 
symptoms,  but  as  there  existed  considerable  nervous  irritability,  tinct. 
hyoscyami  was  prescribed  as  an  anodyne,  and  fomentations  of  hops 
applied  locally.  On  the  third  day,  leeches  were  applied  to  the  neck, 
and  after  this  the  swelling  so  much  subsided,  that  on  the  fifth  day  an 
irregularity  was  discovered  to  exist  in  the  region  of  the  axis  and  atlas, 
which  had  many  of  the  features  of  a  partial  luxation  of  these  vertebrae. 

"At  this  time  he  began  to  walk  about  the  room,  having  previously 
remained  quiet  on  account  of  the  pain  he  suffered  on  moving.  He 
persisted  in  helping  himself,  and  almost  constantly  supported  his  head 
with  one  hand  applied  to  the  occiput.  He  often  remarked,  if  he  could 
be  relieved  of  the  pain  in  his  head  and  neck,  he  should  feel  well.  He 
began  to  relish  his  food,  and  the  swelling  nearly  disappeared  at  the 
end  of  a  week,  leaving  a  protuberance  just  below  the  base  of  the 
occiput,  to  the  left  of  the  central  line  of  the  spinal  column,  with  a 
corresponding  indentation.  Notwithstanding  strict  orders  to  remain 
quietly  at  home,  on  the  ninth  day  after  the  accident  he  rode  out,  and 
in  a  day  or  two  after  returned  as  actively  as  ever  to  his  former  occu- 
pation of  distributing  milk  throughout  the  city  to  his  old  customers. 
During  the  following  four  months  no  material  change  took  place  in 
his  symptoms,  although  he  constantly  complained  of  pain  in  his  head. 
For  this  period  he  did  not  omit  a  single  day  his  round  of  duties  as  a 
milkman,  which  occupied  him  constantly  and  actively  from  five 
o'clock  in  the  morning  to  nearly  noon.  On  the  first  of  November, 
Prof.  Watts  examined  him,  and  inclined  to  the  opinion  that  there  was 
a  luxation  of  the  upper  cervical  vertebrge. 

"About  the  first  of  January,  1853,  the  pains,  from  which  he  had 
been  a  constant  sufferer,  became  more  severe,  and  he  was  heard  to 
complain  that  he  could  not  live  in  his  present  condition  ;  he  remarked, 
also,  that  he  had  heard  a  snapping  in  his  neck.  After  going  his  daily 
round  on  the  eleventh  of  January,  he  complained  of  feeling  cold,  and 
afterwards  of  numbness  in  his  limbs.  In  the  evening  he  had  a  chill, 
and  complained  of  a  pain  in  his  bowels.  He  passed  a  restless  night, 
and  arose  on  the  following  morning  about  six  o'clock ;  he  was  obliged 
to  have  assistance  in  dressing  himself,  and  experienced  a  numbness  of 
his  left,  and  afterwards  of  his  right  side.     He  attempted  to  walk,  but 


FRACTURES    OF    THE    AXIS, 


163 


,Fig.  37. 


could  not  without  help,  and  it  was  observed  that  he  dragged  his  feet. 
He  sat  down  in  a  chair  and  almost  instantly  expired,  at  8  o'clock 
A.  M.,  on  the  12th  of  January,  precisely  five  months  from  the  receipt 
of  the  injury. 

"The  autopsy  was  made  thirty  hours  after  death,  by  Dr.  C.  E. 
Isaacs,  in  presence  of  several  medical  gentlemen.  Muscular  develop- 
ment uncommonly  fine.  An  unusual  prominence  discovered  in  the 
region  of  the  axis  and  atlas.  On  making  an  incision  from  the  occiput 
along  the  spines  of  the  cervical  vertebrae,  the  parts  were  found  to  be 
very  vascular.  These  vertebrae  were  removed  en  masse,  and  a  care- 
ful examination  instituted.  The  transverse,  the  odontoid  (ligamenta 
moderatoria),  as  also  all  the  ligaments  of  this  region,  excepting  the 
occipito-axoideum,  were  in  a  state  of  perfect  integrity ;  this  latter 
was  partially  destroyed.  A  considerable  amount  of  coagulated  blood 
was  found  eft'used  between  the  fractured  surfaces,  some  of  it  apparently 
recent,  but  much  of  it  was  thought  to  have  oc- 
curred at  the  time  of  the  accident,  and  after- 
wards to  have  prevented  the  union  of  the  bones. 
The  spinal  cord  exhibited  no  appearances  of  any 
lesion.  The  odontoid  process  was  found  in  the 
position  well  represented  in  the  accompanying 
illustration,  completely  fractured  ofi',  and  its 
lower  extremity  inclining  backwards  towards 
the  cord.  Death  finally  took  place,  doubtless, 
from  the  displacement  of  the  process  during 
some  unfortunate  movement  of  the  head,  by 
which  pressure  was  made  upon  the  cord.  The 
destruction  of  the  occipito-axoid  ligament, 
which  would  otherwise  have  protected  the 
contents  of  the  spinal  cavity,  must  have  fa- 
vored this  result."^ 

Dr.  Philip  Bevan  presented  to  the  Surgical 
Society  of  Ireland,  in  1862,  a  specimen  ob- 
tained from  the  dead-room,  and  which  was  sup- 
posed to  be  an  epiphyseal  separation  of  the  odontoid  process,  occur- 
ring in  early  life.  The  history  of  the  case  is  not  known,  although 
the  woman  was  forty  years  old  when  she  died.  It  does  not  appear 
very  clear  to  us  whether  this  was  really  an  epiphyseal  separation,  or 
the  result  of  some  morbid  process.^ 

At  the  meeting  of  the  New  York  Pathological  Society,  Nov.  12, 
1868,  Dr.  Austin  Flint  presented  a  case  of  separation  of  the  odontoid 
process  of  the  axis. 

Dr.  W.  Bayard,  of  St.  John,  N.  B.,  has,  however,  reported  a  case  of 
separation  of  the  odontoid  process  in  a  child,  followed  by  complete 
recovery.  In  August,  1864,  Charlotte  Magee,  of  St.  John,  get.  6  years, 
previously  in  excellent  health,  fell  five  feet,  striking  on  her  head  and 


Fracture  of  the  odontoid  pro- 
cess of  the  axis.  Parker's  case. 
A.  Broken  surface.  B.  Odon- 
toid process. 


'  Bigelow,  New  York  Joiirn.  Med.,  March,  1853,  p.  104. 

2  Bevan,  Am.  Journ.  Med.  Sci.,  April,  1864.    From  Dublin  Med.  Press,  Feb.  18, 
1863. 


164  FRACTUEES  OF  THE  VERTEBRA. 

neck,  causing  an  immediate  immobility  of  the  head,  which  continued 
about  two  years  and  a  half,  when  an  abscess  formed  in  the  back  of 
the  pharynx,  and  the  bone  was  spontaneously  discharged.  Since 
then  she  has  been  able  to  move  the  head  freely,  and  her  recovery  may 
be  said  to  be  complete.^  The  specimen  was  subsequently  presented 
to  the  N.  Y.  Pathological  Society,  and  no  doubt  remains  that  the  en- 
tire process  was  thrown  off. 

Dr.  Stephen  Smith  has  kindly  furnished  me  with  a  resume  of  a  pa- 
per he  is  now  preparing  for  the  press,  upon  the  subject  of  fractures 
of  the  odontoid  process.  He  has  already  collected  nineteen  cases,  and 
he  does  not  think  the  enumeration  is  yet  complete.  The  ages  of  the 
patients  range  from  3  years  to  68.  Three  recovered ;  one  of  whom  was 
the  girl  Magee,  to  whom  reference  has  been  made,  after  the  separation 
and  escape  of  the  odontoid  process  ;  the  second  was  a  person  aged  38, 
in  which  case  the  body  of  the  axis  was  discharged,  and  the  process 
was  retained;  the  particulars  of  the  third  case  are  not  given.  Two 
are  recorded  as  sudden  deaths  ;  three  lived  five  days,  and  the  remain- 
der survived  several  weeks  or  months,  one  dying  so  long  as  twenty- 
seven  months  after  the  fracture.  Of  the  whole  number,  two  were  dis- 
secting-room subjects,  and  the  histories  are  not  known. 

§  6.  Fractures  of  the  Atlas. 

I  have  been  able  to  find  only  one  example  of  a  fracture  of  the  atlas 
alone,  and  this  is  the  case  related  by  Sir  Astley  Cooper  as  having 
come  under  the  observation  of  Mr.  Cline. 

A  boy,  about  three  years  old,  injured  his  neck  in  a  severe  fall;  in 
consequence  of  which  he  was  obliged  to  walk  carefully  upright,  as 
persons  do  when  carrying  a  weight  on  the  head  ;  and  when  he  wished 
to  examine  any  object  beneath  him,  he  supported  his  chin  upon  his 
hand,  and  gradually  lowered  his  head,  to  enable  him  to  direct  his 
eyes  downwards.  In  the  same  manner,  also,  he  supported  his  head 
from  behind  in  looking  upwards.  Whenever  he  was  suddenly  shaken 
or  jarred,  the  shock  caused  great  pain,  and  he  was  obliged  to  support 
his  chin  with  his  hands,  or  to  rest  his  elbows  upon  a  table,  and  thus 
support  his  head.  The  boy  lived  in  this  condition  about  one  year, 
and  after  death  Mr.  Cline  made  a  dissection,  and  ascertained  that  the 
atlas  was  broken  in  such  a  manner  that  the  odontoid  process  of  the 
axis  had  lost  its  support,  and  was  constantly  liable  to  fall  back  upon 
the  spinal  marrow.* 

§  7.  Fractures  op  the  First  two  Cervical  Vertebra  (Atlas  and 
Axis)  at  the  same  tiiME. 

A  woman,  aet.  68,  fell  down  a  flight  of  steps,  striking  upon  her  fore- 
head, and  died  immediately.  Upon  making  a  dissection,  it  was  found 
that  the  atlas  was  broken  upon  both  sides  near  the  transverse  pro- 

'  Bayard,  Canada  Med.  Journ.,  Dec.  1869. 
2  Cline,  Sir  Astley  Cooper,  op.  cit.,  p.  459. 


TRACTUEES    OF    THE    STERNUM.  165 

cesses,  and  the  odontoid  process  of  the  axis  was  broken  at  its  base. 
These  fractures  were  accompanied  with  a  rupture  of  the  atloido-odon- 
toid  ligaments,  and  a  dislocation  of  the  atlas  backwards.^ 

South  says  there  is  a  specimen  in  the  museum  of  St.  Thomas's  Hos- 
pital, showing  this  double  fracture.  The  man  had  received  his  injury 
only  a  few  hours  before  admission  to  the  hospital,  and  died  on  the 
fifth  day.  On  examination,  the  atlas  was  found  to  be  broken  in  two 
places,  and  the  odontoid  process  of  the  axis  at  its  root.  The  fifth  ver- 
tebra was  also  broken  through  its  body.  With  neither  fracture  was 
there  sufficient  displacement  to  produce  pressure,  but  a  small  quantity 
of  extravasated  blood  lay  in  the  substance  of  the  spinal  marrow,  and 
its  tissue  was  at  one  point  broken  down  and  disorganized.^ 

Mr.  Phillips  relates  that  a  man  fell  from  a  hay-rick,  striking  upon 
the  occiput ;  after  which,  although  momentarily  stunned,  he  walked 
half  a  mile  to  the  parish  surgeon,  and  in  two  days  more  he  returned 
to  his  occupation.  About  four  weeks  after  the  accident  he  was  seen 
by  Mr.  Phillips,  who  discovered  a  small  tumor  over  the  second  cervi- 
cal vertebra,  pressure  upon  which  caused  a  slight  pain.  He  com- 
plained also  that  his  neck  was  stiff,  and  that  he  was  unable  to  rotate 
it.  No  other  disturbance  of  the  functions  of  the  body  could  be  dis- 
covered. After  a  time  the  tonsils  became  swollen,  and  the  patient 
experienced  some  difficnlty  in  deglutition,  and,  upon  examining  the 
throat,  a  slight  projection  or  fulness  was  discovered  at  the  back  of 
the  larynx,  opposite  the  second  cervical  vertebra.  Subsequently  he 
became  afiected  with  general  anasarca  and  pleuritic  effusions,  of  which 
he  finally  died.  Up  to  the  last  week  of  his  life  he  was  able  to  walk 
about  his  bedroom,  and  his  condition  presented  no  other  evidence 
than  has  been  mentioned,  that  he  was  suffering  from  an  injury  of  the 
spine.     He  died  forty-seven  weeks  after  the  receipt  of  the  injury. 

The  autopsy  disclosed  a  fracture  with  displacement  of  the  atlas,  and 
a  fracture  of  the  odontoid  process  of  the  axis.  The  two  vertebrae 
were  united  to  each  other  firmly  by  complete  bony  callus.^ 


CHAPTER    XVI. 

FRACTURES  OF  THE  STERNUM. 

Fractures  of  the  sternum  are  of  rare  occurrence,  owing,  probably, 
to  the  elasticity  of  the  ribs  and  their  cartilages,  upon  which  it  mainly 
rests,  and  also,  in  part,  to  the  softness  of  its  structure.  In  advanced 
life,  the  ossification  and  fusion  of  all  of  its  several  portions  becoming 
more  complete,  and  the  cartilages  of  the  ribs  also  becoming  more  or 
less  ossified,  its  fracture  is  relatively  more  frequent. 

'  Malgaigne,  op.  cit.,  torn.  ii.  p.  333. 

2  Chelius'  Surgery,  note  by  South,  vol.  i.  p.  588. 

3  Phillips,  Med.-Chir.  Trans.,  vol.  xx.  1837,  p.  384. 


166  FRACTURES    OF    THE    STERNUM. 

Games. — They  are  generally  the  result  of  direct  blows  inflicted  upon 
the  part,  such  as  the  passage  of  a  loaded  vehicle  across  the  chest,  the 
fall  of  a  tree  or  of  some  heavy  timber  upon  the  body;  the  fracture 
implying  always  that  great  force  has  been  applied. 

Indirect  blows,  and  voluntary  muscular  action  alone  have  been 
known  also  occasionally  to  produce  this  fracture. 

David,  in  his  Memoire  eur  les  Contrecoups,  published  as  a  prize 
essay  by  the  Academy  of  Medicine,  mentions  the  case  of  a  mason,  who, 
in  falling  from  a  great  height,  struck  upon  his  back  against  a  cross- 
bar which  intercepted  his  fall,  in  consequence  of  which  the  abdominal 
and  sterno-cleido-mastoidean  muscles  were  so  stretched  that  the  ster- 
num broke  asunder  between  its  upper  and  middle  portions.^  Sabatier 
reports  another  case  of  fracture  at  the  same  point,  produced  in  a  simi- 
lar manner;^  and  Roland  has  described  a  third  example  in  a  woman 
sixty-three  years  old,  who,  falling  from  a  height  backwards  and  strik- 
ing upon  her  back,  broke  the  sternum  near  its  centre.^ 

Cruveilhier  saw  a  man  who,  having  fallen  from  a  height  of  twenty 
feet  upon  his  nates,  was  found  to  have  a  fracture  of  the  sternum.* 
Cussan  saw  the  same  result  in  a  person  who  fell  from  a  third  story, 
striking  first  upon  his  feet  and  then  pitching  over  upon  his  back.* 
Maunoury  and  Thore  have  reported  an  analogous  case,  where  a  man 
fell  from  a  height  of  twelve  or  fifteen  metres,  first  striking  upon  his 
feet  and  then  falling  over  upon  his  back  and  head.^  Mr.  Johnson, 
late  editor  of  the  London  Med.-Chir.  Rev.,  reports  a  case  of  this  kind, 
also,  as  having  been  received  into  St.  George's  Hospital,  in  London  ; 
the  man,  a  healthy  laborer  from  the  country,  had  fallen  from  the  top 
of  a  hay-cart,  striking  only  upon  his  head.  He  walked  with  his  head 
much  bent  forwards,  and  was  incapable  of  either  flexing,  extending, 
or  rotating  it  any  farther.  The  fracture  was  transverse,  and  about 
three  inches  below  the  top  of  the  sternum,  opposite  the  centre  of  the 
third  rib,  the  lower  fragment  projecting  in  front  of  the  upper.  The 
fragments  were  easily  replaced  by  simply  throwing  the  head  back, 
and  fell  into  place  with  an  audible  snap,  but  immediately  resumed 
their  unnatural  position  when  the  head  was  flexed.  They  finally 
united,  but  with  a  slight  projection  and  overlapping.''  Gross  has 
reported  one  more  example." 

Malgaigue  expresses  a  doubt  whether  all  these  can  be  considered 
as  the  results  of  muscular  action,  since,  in  a  certain  number  of  the 
examples  cited,  the  head  seems  to  have  been  thrown  forwards  by  the 
concussion,  and  in  others,  also,  there  is  no  evidence  that  the  muscles 
attached  to  the  sternum  were  put  upon  the  stretch.  The  only  remain- 
ing explanation  is  that  in  such  cases  the  sternum  has  been  broken  by 
the  violent  shock,  or  contrecoup. 

'  Boyer  on  Bones,  p.  57. 

2  Malgaigne,  from  Sabatier,  Mem.  sur  la  Fract.  du  Sternum. 

3  Ibid.,  from  Bull,  de  Therap.,  tom.  vi.  p.  288. 

*  Ibid.,  from  Bull,  de  la  Soc.  Anat.,  Juin,  1836. 

5  Ibid.,  from  Archiv.  de  Med.,  Janv.  1827. 

6  Ibid.,  from  Gaz.  Med.,  1842,  p.  361. 

'  London  Med.-Chir.  Rev.,  vol.  xvii.,  new  scries,  p.  536,  1832. 

*  Gross,  System  of  Surg.,  vol.  ii.  p.  167. 


FRACTUEES    OF    THE    STERNUM. 


167 


-The  sternum  is  separated  mostfre- 


Fiff.  38. 


"I   rcfreli/  unite , 


35-1,0, 


ZO-2Jifh  ,, 


year 


soon  afUr  vaiertif 


part  It/  carlila^iiioas  in 

adiranccd  life 

Sternum,  showing  the  periods  at  which  Its  several 
parts  unite  hy  boue.     (From  Gray.) 


Seat  and  Direction  of  Fracinre.- 
quently  either  in  the  long  cen- 
tral portion,  or  at  the  junction 
of  this  with  the  upper  portion, 
where  the  bone  is  weakest.  In 
fact,  a  separation  at  this  latter 
point  may  be  regarded  fre- 
quently as  a  diastasis  or  dislo- 
cation rather  than  as  a  fracture, 
since  the  two  portions  do  not 
become  firmly  united  by  bone 
until  late  in  life.  The  very  late 
ossification  and  fusion  of  the 
xiphoid  cartilage  with  the  cen- 
tral piece,  also,  will  explain  the 
infrequeucy  of  its  fracture. 

Boj^er  believed  that  the  xi- 
phoid cartilage  was  not  suscepti- 
ble of  being  permanently  dis- 
placed backwards,  except  in 
aged  persons,  after  it  had  become  ossified,  "for,"  he  says,  "though 
violently  struck  and  driven  backwards  by  a  blow  on  what  is  vulgarly 
termed  the  pit  of  the  stomach,  yet  it  restores  itself  by  its  own  elas- 
ticity."^ 

The  following  case,  however,  which  has  come  under  my  own  ob- 
servation, is  conclusive  as  to  the  possibility  of  this  accident: — 

A  man,  twenty-eight  years  old,  fell  forwards,  striking  the  lower  end 
of  his  sternum  upon  the  top  of  a  candlestick,  breaking  in  the  xiphoid 
cartilage.  During  two  3'ears  fallowing  the  accident  he  had  frequent 
attacks  of  vomiting,  which  were  excessively  violent  and  distressing; 
the  paroxysms  occurring  every  five  or  six  days.  Both  Dr.  Green, 
of  Albany,  and  Dr.  White,  of  Cherry  Valley,  upon  whom  he  called  for 
relief,  recommended  excision  of  the  cartilage,  but  the  patient  would 
not  submit  to  the  operation.  Twelve  years  after  the  accident,  in  the 
year  1848,  while  he  was  an  inmate  of  the  Buffalo  Hospital  of  the 
Sisters  of  Charity,  I  examined  his  chest,  and  found  the  xiphoid  carti- 
lage bent  at  right  angles  with  the  sternum,  pointing  directly  towards 
the  spine.  He  now  suffered  no  inconvenience  from  it,  except  that  it 
hurt  him  occasionally  when  he  coughed.^ 

The  upper  portion  of  the  sternum  is  rarely  broken,  unless  at  the 
same  time  the  central  portion  is  broken  also. 

The  direction  of  these  fractures  is  generally  transverse,  or  nearly 
so;  occasionally  a  slight  obliquity  is  found  in  the  direction  of  the 
thickness  of  the  bone.  In  three  or  four  examples  upon  record,  the 
direction  of  the  fracture  was  longitudinal.  It  is  not  so  unfrequent, 
however,  to  find  the  bone  comminuted.  Compound  fractures  are 
exceedingly  rare. 


'  Boyer  on  Diseases  of  Bones,  p.  59. 

2  Buffalo  Med.  Journ.,  vol.  xii.  p.  282,  Cases  of  Fractures  of  the  Sternum. 


168  FEACTUKES    OF    THE    STERNUM. 

When  the  fracture  is  transverse,  the  lower  fragment  is  almost 
always  displaced  forwards,  and  sometimes  it  slightly  overlaps  the 
upper  fragment. 

In  one  instance  mentioned  by  Sabatier,  where  the  separation  had 
taken  place  at  the  point  of  junction  between  the  first  and  second 
pieces,  the  lower  fragment  was  displaced  backwards,  and  was  also  car- 
ried upwards  under  the  upper  fragment  to  the  extent  of  twenty-eight 
milliinetres. 

I  have  seen  a  remarkable  case  of  separation  of  the  manubrium 
from  the  gladiolus,  accompanied  with  a  true  fracture  and  other 
complications. 

Louis  Wilson,  get.  60,  was  admitted  into  the  Long  Island  College 
Hospital,  April  4,  1866,  having  just  fallen  through  the  hatchway  of  a 
vessel.  He  had  a  compound  comminuted  fracture  of  the  right  leg; 
a  fracture  of  the  four  first  ribs  on  each  side  at  their  necks ;  a  dislo- 
cation of  the  sternum  from  the  cartilages  of  both  second  ribs;  a 
dislocation  of  the  left  third  cartilage  from  its  rib  ;  a  dislocation  of  the 
first  from  the  second  bone  of  the  sternum  ;  and  a  transverse  fracture 
of  the  sternum  three-quarters  of  an  inch  below  the  top  of  the  gladiolus. 
The  dislocation  of  the  manubrium  was  complete,  and  it  was  thrust 
behind  the  upper  end  of  the  gladiolus,  underlapping  it  half  an  inch. 
The  transverse  fracture  three-quarters  of  an  inch  lower  down  was 
also  complete,  and  the  fragment  thus  separated  was  divided  into  two, 
namely,  an  anterior  and  a  posterior  fragment,  by  a  transverse  splitting; 
the  anterior  moiety  retaining  its  attachment  to  the  periosteum  below, 
and  not  being  displaced,  while  the  posterior  moiety  retained  its 
attachment  to  the  periosteum  both  above  and  below,  and  was  pushed 
downwards  by  the  descent  of  the  manubrium.  His  mind  was  clear, 
but  he  had  paralysis  of  the  bladder,  and  was  breathing  with  some 
embarrassment.  I  had  no  difficulty  in  diagnosticating  the  dislocation 
of  the  third  cartilage,  and  of  the  manubrium.  There  was  no  swelling 
or  discoloration  on  the  front  of  the  chest,  but  it  was  quite  tender.  His 
head  was  not  thrown  forward.  He  complained  of  some  soreness  on 
the  back  of  his  head.  His  general  condition  was  such  that  I  did  not 
attempt  reduction.  The  following  day  he  expectorated  blood,  and  on 
the  third  day  he  died.  The  autopsy  revealed  some  effusions  of  blood 
underneath  the  pleura,  but  no  lesions  of  the  heart  or  lungs.  The 
evidence  is  in  this  case  conclusive  that  he  struck  upon  his  back  and 
head,  in  fact  that  it  was  a  fracture  from  counter-stroke,  by  which  the 
head,  neck,  and  three  or  four  upper  vertebrae  were  bent  forward  with 
great  force,  thus  doubling  forward  the  top  of  the  sternum. 

Dr.  Robert  Watts,  Jr.,  of  this  city,  has  reported  a  very  similar  case, 
in  which  death  occurred  on  the  same  day.  The  fragments  of  the 
sternum  were  not  displaced,  but  the  ribs  had  suffered  similar  lesions.^ 

Diagnosis. — In  a  few  cases  the  patients  have  felt  the  bone  break  at 
the  moment  of  the  accident.  When  displacement  exists,  it  may  gene- 
rally be  easily  recognized,  and  the  lower  fragment  will  often  be  seen 
to  move  forwards  and  backwards  at  each  inspiration  and  expiration. 

»  Watts,  Am.  Med.  Times,  vol.  iii.  p.  55. 


FRACTURES    OF    THE    STERNUM.  169 

Crepitus  may  also  be  detected  in  some  of  these  examples,  but  it  is  less 
often  present  where  no  displacement  exists.  To  determine  the  exist- 
ence of  crepitus,  the  hand  should  be  placed  over  the  supposed  seat  of 
fracture,  while  the  patient  is  directed  to  make  forced  inspirations  and 
expirations,  or  the  ear  may  be  applied  directly  to  the  chest. 

Emphysema  has,  also,  occasionally  been  noticed,  indicating  usually 
that  the  lungs  have  been  penetrated  by  the  broken  fragments. 

The  frequent  occurrence  of  congenital  malformations  of  the  sternum 
should  warn  us  to  exercise  great  care  in  our  examinations,  lest  we 
mistake  these  natural  irregularities  for  fractures.  Bransby  Cooper 
mentions  a  remarkable  instance  of  malformation  of  the  xiphoid  car- 
tilage which  he  at  first  suspected  to  be  a  fracture.  It  was  so  much 
curved  backwards  that,  as  Mr.  Cooper  thinks,  its  pressure  upon  the 
stomach  produced  a  constant  disposition  to  vomit  whenever  he  had 
taken  a  full  meal,  or  had  taken  a  draught  of  water.^ 

Prognosis. — In  simple  fracture  of  this  bone,  uncomplicated  with 
lesions  of  the  subjacent  viscera,  and  especially  when  the  fracture  is 
the  result  of  muscular  action  or  of  a  counter-stroke,  no  serious  con- 
sequences are  to  be  apprehended.  The  bone  unites  promptly  even 
where  it  is  found  impossible  to  bring  its  broken  edges  into  appo- 
sition. Indeed,  generally,  where  the  fragments  have  been  once  com- 
pletely displaced,  although  it  is  not  difficult  to  replace  them  momen- 
tarily, a  re-displacement  soon  occurs,  and  they  are  found  finally  to 
have  united  by  overlapping ;  but  no  evil  consequences  usually  result 
from  this  malposition.  In  nearly  all  of  the  cases  reported  in  which 
palpitations,  difficult  breathing,  &c.,  have  been  charged  to  the  persist- 
ence of  the  displacement,  the  injuries  were  of  such  a  character  as  to 
furnish  for  these  unfortunate  results  other  and  much  more  adequate 
explanations.  In  one  instance  only,  already  mentioned,  serious  incon- 
veniences followed  from  a  displacement  of  the  cartilage  backwards. 

In  other  cases,  however,  where  the  fracture  is  the  result  of  a  direct 
blow,  constituting  a  large  majority  of  the  whole  number,  the  prognosis 
is  often  very  grave ;  a  conclusion  to  which  one  would  naturally  ar- 
rive from  the  fact  already  stated,  that  the  fracture  of  the  sternum  thus 
produced,  in  itself  implies  the  application  of  great  force. 

An  abscess  occurrmg  in  the  anterior  mediastinum,  and  caries  or 
necrosis  of  the  bone,  are  among  the  most  common  results  of  a  blow 
delivered  directly  upon  the  sternum  ;  complications  which  generally 
end  sooner  or  later  in  death.  Blood  may  be  also  extensively  eft'used 
into  the  anterior  mediastinum. 

A  remarkable  case  of  recovery  after  gunshot  injury  of  the  sternum 
is  reported  by  the  U.  S.  Medical  Bureau : — 

Private  C.  Betts,  26th  N.  J.  Vols.,  ast.  22,  was  struck  by  a  three- 
ounce  grape-shot,  May  3,  1863,  in  the  charge  upon  the  heights  at 
Fredericksburg,  Va.  The  ball  comminuted  the  sternum,  opposite  the 
third  rib  on  the  left  side,  penetrating  the  costal  pleura.  The  patient 
removed  the  ball  from  the  wound  himself.  On  the  following  day  he 
was  admitted  to  the  hospital  of  the  second  division  of  the  sixth  corps. 

•  B.  Cooper,  Princ.  and  Pract.  of  Surg.,  p.  359. 
12 


170  FEACTUEES    OF    THE    STEEJS'UM. 

Through  the  wound  the  arch  of  the  aorta  was  distinctly  visible,  and 
its  pulsations  could  be  counted.  The  leit  lung  was  collapsed;  when 
sitting  up,  there  was  but  slight  dyspnoea.  Several  fragments  of  the 
sternum  were  removed.  The  wound  soon  began  to  heal,  and  he  made 
a  complete  recovery.* 

Where  emphysema  is  present,  we  may  anticipate  inflammation  of 
the  pleura  and  of  the  lungs. 

In  several  instances,  where  death  has  occurred  speedily  after  the 
injury,  the  heart  has  been  found  penetrated  and  torn  by  the  fragments, 
Sanson  and  Dupuytren  have  each  reported  one  example  of  this  kind. 
Duverney  has  mentioned  two,  and  Samuel  Cooper  says  there  is  a 
specimen  in  the  museum  of  the  University  College,  exhibiting  a  lace- 
ration of  the  right  ventricle  of  the  heart  by  a  portion  of  fractured 
sternum.  Watson  mentions  a  case  in  which  the  pericardium  was 
torn,  but  the  heart  was  only  contused.^ 

Treatment. — When  the  fragments  are  not  displaced,  the  only  indi- 
cations of  treatment  are  to  immobilize  the  chest,  and  to  allay  the  in- 
flammation, pain,  &c.,  consequent  upon  the  injury  to  the  viscera  of  the 
chest.  The  first  of  these  indications  is  accomplished,  at  least  in  some 
degree,  by  inclosing  the  body,  from  the  armpits  down  to  the  margin 
of  the  floating  ribs,  with  a  broad  cotton  or  flannel  band.  A  single 
band,  neatly  and  snugly  secured,  and  made  fast  with  pins,  is  preferable 
to,  because  it  is  more  easily  applied  than,  the  roller  which  surgeons 
have  generally  employed;  it  is  also  much  less  liable  to  become  dis- 
arranged. It  should  be  pinned  while  the  patient  is  making  a  full 
expiration.  To  prevent  its  sliding  down,  two  strips  of  bandage  should 
be  attached  to  its  upper  margin,  and  crossed  over  the  shoulders  in  the 
form  of  suspenders. 

Generally  the  patients  prefer  the  half-sitting  posture,  with  the  head 
and  shoulders  thrown  a  little  backwards ;  and  this  is  the  position 
which  will  be  most  likely  to  maintain  the  fragments  in  place,  and  also 
to  secure  immobility  to  the  external  thoracic  muscles,  while  it  leaves 
the  diaphragm  and  the  abdominal  muscles  free  to  act. 

The  second  indication  may  demand  the  use  of  the  lancet ;  but  more 
often  it  will  be  found  necessary  to  allay  the  pain  and  disposition  to 
cough  by  the  use  of  opium. 

If,  however,  the  fragments  are  displaced,  it  is  proper  first  to  attempt 
their  reduction;  which,  as  we  have  already  intimated,  is  generally 
more  easy  of  accomplishment  than  is  the  maintenance  of  them  in  place 
until  a  cure  is  effected. 

The  upper  fragment  may  be  thrown  forwards,  and  made  to  resume 
its  position  sometimes  by  a  single  full  inspiration  ;  but  then  it  usually 
falls  back  during  expiration;  or  it  may  be  reduced  by  straightening 
the  spine  forcibly,  and  at  the  same  time  drawing  the  shoulders  back. 

Verduc  and  Petit  proposed,  in  those  cases  in  which  it  was  found 
impossible  to  reduce  the  fragments  by  these  sim.ple  means,  to  cut 
down  and  lift  the  depressed  bone.     N^latou  suggests  the  use  of  a  blunt 

'  Circular  No.  6,  AYashington,  D.  C,  Nov.  1,  1865,  p.  23. 
2  New  York  Journ.  Med.,  vol.  ill.  p.  351. 


FRACTUEES    OF    THE    STERNUM.  171 

crotchet  introduced  through  a  narrow  incision  ;  and  Malgaigne  has 
thought  of  another  plan,  which  is,  to  penetrate  the  skin  with  a  punch, 
and  directing  it  to  the  broken  margin,  to  push  the  fragment  into  its 
place,  but  which  he  does  not  himsell'  regard  as  a  suggestion  of  much 
value,  since  the  bone  is  too  soft  to  afford  the  necessary  resistance ;  and, 
moreover,  this,  in  common  with  all  of  the  other  similar  methods,  is 
liable,  in  some  degree,  to  the  objection  that  it  may  increase  the  ten- 
dency to  caries  and  suppuration,  already  imminent.  If  reduced,  the 
fragments  will  probably  immediately  again  become  displaced  ;  and 
more  than  all,  it  still  remains  to  be  proven  conclusively  that  the  mere 
riding  of  the  fragments  is  in  itself  ever  a  cause  of  subsequent  suffering, 
or  even  of  inconvenience. 

When  an  abscess  has  formed  in  the  anterior  mediastinum,  surgeons 
have  occasionally  recommended  the  use  of  the  trephine.  Gibson  has 
twice  operated  in  this  manner  at  the  Philadelphia  Hospital,  but  in 
each  case  the  caries  continued  to  extend,  and  the  patient  died ;  an 
experience  which  has  inclined  him  latterly  to  discountenance  the 
operation.^ 

There  are  other  considerations  mentioned  by  Lonsdale,  which  ought 
to  decide  us  never  to  use  the  trephine  in  these  cases.  "  For  the  symp- 
toms denoting  the  presence  of  the  abscess,  when  completely  confined 
to  the  under  surface  of  the  bone,  will  be  very  uncertain  ;  and  when 
the  matter  collects  in  large  quantities,  it  will  show  itself  at  the  margin 
of  the  sternum,  between  the  ribs;  when  it  can  be  let  out  by  making 
a  puncture  with  the  point  of  a  lancet,  without  the  necessity  of  remov- 
ing a  portion  of  the  bone."^  Ashhurst,  rel'erring  to  the  same  point, 
remarks:  "The  fact  that  the  mediastinal  space  can  be  cut  into  with- 
out injury  to  the  pleura  is  shown  by  many  cases,  among  others  by 
one  which  came  under  my  own  observation."^ 

We  have  already  said  that  a  separation  of  the  first  from  the  second 
piece  of  the  sternum,  occurring  before  ossific  union  had  taken  place, 
might  with  some  propriety  be  regarded  as  a  diastasis,  or  as  a  dislo- 
cation even.  Maisonneuve,  Vidal  (de  Casis),  Malgaigne,  and  other 
French  surgeons  speak  of  it  as  a  dislocation,  and  Vidal  has  collected 
five  examples,  in  all  of  which  the  lower  bone  occupied  a  position  in 
front  of  the  upper.  Malgaigne  enumerates  ten  examples.  The  points 
of  difference  between  the  dislocation  and  the  true  fracture  are  too 
small,  however,  to  demand  of  us  especial  attention. 

'  Gibson,  Institutes  and  Practice  of  Surgery,  vol.  i.  p.  269. 

2  Lonsdale,  Practical  Treatise  on  Fractures,  London,  1838,  p.  243. 

3  Ashhurst,  Am.  Journ.  Med.  Sci.,  Jan.  and  Oct.  18(53. 


172      FRACTURES    OF    THE    RIBS    AND    THEIR    CARTILAGES. 


CHAPTER    XVII. 

FRACTURES  OF  THE  RIBS  AND  THEIR  CARTILAGES. 

§  1.  Fractures  of  the  Ribs. 

Fractures  of  the  ribs,  observed  more  often  than  fractures  of  the 
sternum,  are  rare  as  compared  with  fractures  of  other  long  bones. 

In  my  records,  not  including  fractures  from  gunshot  injuries,  only 
twenty-five  patients  are  reported  as  having  had  broken  ribs ;  but  as 
in  several  of  the  cases  two  or  more  ribs  were  broken  at  the  same  time, 
the  total  number  of  fractures  is  about  fifty-eight.  If,  however,  I  had 
always  accepted  the  diagnosis  made  by  other  surgeons,  the  number 
would  have  been  much  greater,  since  I  have  been  repeatedly  assured 
that  the  ribs  were  broken  when,  upon  the  most  rigid  examination,  no 
evidence,  beyond  the  existence  of  a  severe  pain  and  of  difficult  res- 
piration, has  been  presented  to  me. 

Etiology. — The  force  requisite  to  break  the  ribs  is  scarcely  less  than 
what  is  requisite  to  break  the  sternum;  and  in  childhood  and  infancy 
it  is  sometimes  almost  impossible  to  break  them,  so  that  children  and 
even  adults  are  often  crushed  and  killed  outright,  where,  although  the 
pressure  has  been  directly  upon  the  thorax,  the  ribs  have  resumed 
their  positions,  and  have  been  found  not  to  be  broken.  I  have  met 
with  several  examples  of  this  kind. 

In  old  age,  the  cartilages  ossify  and  the  ribs  themselves  suffer  a 
gradual  atrophy,  which  renders  them  much  more  liable  to  break. 

The  most  common  causes  are  direct  blows,  of  very  great  force,  in 
consequence  of  which  sometimes  the  fragments  are  not  only  broken, 
but  more  or  less  forced  inwards ;  occasionally  they  are  the  result  of 
counter-strokes,  and  then  the  fragments,  if  they  deviate  at  all  from 
their  natural  position,  are  salient  outwards ;  a  species  of  fracture 
which  I  have  not  met  with  so  often. 

Malgaigne  has  collected  eight  examples  of  fractures  of  the  ribs  pro- 
duced by  muscular  action,  by  the  beating  of  the  heart,  &c.,  all  of  which 
occurred  upon  the  left  side.  It  is  believed,  however,  that  in  all  of 
these  cases  the  ribs  had  previously  become  atrophied,  and  perhaps 
undergone  other  changes  in  their  structure,  rendering  them  liable  to 
fracture  from  the  action  of  trivial  causes. 

Pathology,  Seat,  &c. — The  fourth,  fifth,  sixth,  and  seventh  ribs  are 
most  liable  to  be  broken  ;  the  upper  ribs,  and  especially  the  first  rib, 
being  so  well  protected  in  various  waj's  as  to  greatly  diminish  their 
liability,  while  the  loose  and  floating  condition  of  the  last  two  ribs 
gives  them  an  almost  complete  exemption. 

In  my  own  cases  I  have  found  the  first,  second,  and  third  ribs  each 
broken  four  times;  the  fourth,  six  times;  the  fifth,  twelve  times  ;  the 


FRACTURES    OF    THE    RIBS.  173 

sixth,  twelve  times;  the  seventh,  nine  times;  the  eighth,  ninth,  and 
tenth,  twice  each. 

Twenty-one  were  broken  through  their  anterior  thirds,  generally  at 
or  near  the  junction  of  the  cartilages  with  the  ribs  ;  ten  through  their 
middle  thirds;  and  twenty  through  their  posterior  thirds.  Mal- 
gaigne  has  noticed,  also,  contrary  to  the  general  opinioh  of  surgeons, 
that  the  ribs  are  most  often  broken  in  their  anterior  thirds,  whether 
the  cause  has  been  a  direct  or  a  counter  blow. 

The  direction  of  the  fracture  is  generally  transverse  or  slightly  ob- 
lique; sometimes  it  is  quite  oblique.  It  is  often  compound;  and  in 
a  few  instances  I  have  found  it  comminuted  or  multiple.  Where  the 
fracture  is  compound,  it  is  rendered  so  generally  by  the  fragments 
Laving  penetrated  the  lungs,  and  not  by  a  tegumentary  wound.  In 
only  twelve  of  the  twenty-five  cases  recorded  by  me,  has  the  fracture 
been  uncomplicated  with  fractures  or  dislocations  of  other  bones. 

Displacement  cannot  occur  in  the  direction  of  the  axis  of  the  bone 
unless  several  ribs  are  broken  at  the  same  time.  The  fragments  are 
therefore  either  not  at  all  displaced,  or  they  fall  inwards  toward  the 
cavity  of  the  chest,  or  outwards,  or  very  slightly  downwards,  in  the 
direction  of  the  intercostal  spaces.  Sometimes  the  rib  moves  a  little 
upon  its  own  axis. 

Prognosis. — Death  occurs  sooner  or  later  in  a  pretty  large  propor- 
tion of  the  cases  in  which  the  ribs  have  been  broken ;  yet  not  often 
as  a  direct  consequence  of  the  fracture,  but  only  as  a  result  of  the 
injury  inflicted  upon  the  viscera  of  the  chest,  or  of  other  injuries  re- 
ceived at  the  same  moment.  The  violent  compression  of  the  heart 
and  lungs  has  frequently  produced  death,  and  sometimes,  as  I  have 
more  than  once  seen,  almost  immediately  ;  or  the  patients  have  suc- 
cumbed at  a  later  period  to  acute  pneumonitis. 

Lonsdale  saw  a  case  in  which  the  body  of  a  man  having  been  tra- 
versed by  the  wheel  of  a  wagon,  eight  ribs  were  broken,  and  death 
having  followed  almost  imm.ediately,  the  autopsy  disclosed  a  rent  in 
the  left  auricle  of  the  heart,  produced  by  one  of  the  broken  ribs.' 
South  says  there  is  sucb  a  specimen  at  St.  Thomas's  Hospital.^ 

Dupuytren  reports  a  similar  case.  The  same  surgeon  has  also  seen 
several  deaths  produced  by  the  emphysema,  independent  of  the  frac- 
ture, two  of  which  are  particularly  described  in  his  Clinical  Lectures.^ 
Amesbury  has  seen  a  case  of  death  from  rupture  of  the  intercostal 
artery,  where  there  was  no  injury  of  the  lungs.^ 
"^  In  several  instances  observed  by  me,  patients  have  suffered  from 
pains  in  the  side,  occasionally  from  cough,  &c.,  after  the  lapse  of  two 
or  more  years,  and  I  suspect  it  is  no  uncommon  thing  for  these  injuries 
to  entail  some  such  permanent  disability,  but  which  is  a  consequence 
rather  of  the  injury  to  the  viscera  of  the  chest,  than  of  any  condition 
of  the  broken  ribs  themselves. 

In  general,  simple  fractures  of  the  ribs  unite  in  from  twenty-five  to 
thirty  days.     Malgaigue  has  seen  one  case  of  non-union  ;  Huguier  met 

•  Lonsdale  on  Fractures,  p.  258.     2  Chelius's  Surgery,  by  South,  vol.  i.  p.  599 
3  Dupuytren,  op.  cit.,  p.  79.  "  Amesbury  on  Fractures,  vol.  ii.  612. 


174      FKACTURES    OF    THE    EIBS    AND    THEIR    CARTILAGES. 


with  another  upon  the  cadaver,  in  which  a  complete  false  joint  existed, 
furnished  with  a  capsule  and  lined  with  synovial  membrane;^  Eve,  of 
Nashville,  Tenn.,  saw  a  case  of  non-union  occasioned,  probably,  by  a 
caries  or  necrosis  of  the  bone,  since  it  was  accompanied  with  a  dis- 
charge of  matter,  and  in  which  a  removal  of  the  ends  of  the  fragments 
resulted  promptly  in  a  cure  of  the  sinus  ;^  and  Samuel  Cooper  says 
there  is  a  specimen  in  the  Museum  of  the  University  College,  of  a 
fracture  of  six  ribs,  where  the  fragments  are  only  connected  by  a 
fibrous  or  ligamentous  tissue.^ 

The  union  generally  occurs  with  only  a  slight  degree  of  displace- 
ment. 

After  the  union  is  completed,  even  where  there  is  no  displacement, 
a  certain  amount  of  ensheathing  callus  may  generally  be  .felt  at  the 
point  of  fracture.  Of  five  cases  which  I  have  carefully  examined  after 
recovery,  in  only  one  instance  was  I  unable  to  detect  any  irregularity 
at  this  point.     I  have  in  my  cabinet  nine  specimens  of  fractured  ribs, 

in  four  of  which  the  en- 
Fig.  39.  sheathing  callus  is  com- 
pletely formed,  but  the 
fragments  are  in  perfect 
apposition:  in  one,  ap- 
position is  preserved,  but 
there  is  no  ensheathing 
callus  ;  and  the  remain- 
ing four,  all  occurring 
in  the  same  person,  are 
united  with  displace- 
ment, but  without  a  pro- 
per ensheathing  callus. 
In  some  specimens  I 
have  observed  sharp  spicules,  in  others  broader  sheets,  of  bone  ex- 
tending along  the  course  of  the  intercostal  muscles  from  one  rib  to 
the  other,  forming  a  species  of  anchylosis  between  their  adjacent  mar- 
gins. 

Symptomatology. — Acute  pain,  referred  especially  to  the  point  of 
fracture,  sometimes  producing  great  embarrassment  in  the  respiration, 
and  crepitus,  are  the  most  common  indications  of  a  fracture.  The 
pain  and  embarrassed  respiration  are,  however,  far  from  being  diag- 
nostic, since  they  are  often  present  in  an  equal  degree  when  the  walls 
of  the  chest  have  only  been  severely  contused. 

The  crepitus,  also,  is  often  difficult  to  detect,  owing  to  the  thickness 
of  the  muscular  coverings,  or  to  the  amount  of  fat  upon  the  body,  or 
to  the  fracture  having  occurred  perhaps  directly  underneath  the  mam- 
mae in  the  female.  In  three  instances,  where  the  presence  of  emphy- 
sema rendered  the  existence  of  a  fracture  quite  certain,  I  have  been 
unable  immediately  after  the  accident  to  discover  crepitus. 

The  crepitus  may  be  discovered  sometimes  by  pressing  gently  upon 

'  Malgaigne,  op.  cit.,  p.  435.  2  j^ve,  N.  Y.  Journ.  Med.,  vol.  xv.  p.  136. 

3  S.  Cooper's  Surg.,  vol.  ii.  p.  321. 


Fractured  ribs  joined  to  each  other  by  osseous  matter.     (From 
Dr.  Gross's  cabinet.) 


FRACTURES    OF    THE    RIBS.  175 

tlie  seat  of  fracture,  or  by  applying  the  ear  or  the  stethoscope  over 
this  point  while  the  patient  attempts  a  full  inspiration,  or  coup-hs-  or 
we  may  press  upon  the  front  of  the  chest  with  one  hand,  while  the 
fingers  of  the  other  hand  rest  upon  the  fracture. 

Occasionally  the  patient  has  felt  the  bone  break,  and  very  often  he 
feels  or  hears  the  crepitus  after  it  is  broken,  and  will  himself  indicate 
very  clearly  the  point  of  fracture. 

At  the  same  time  that  we  detect  crepitus  we  are  able  also  to  discover 
motion  in  the  fragments,  but  I  have  once  or  twice  discovered  preter- 
natural mobility  without  crepitus. 

Emphysema,  which  is  almost  certainly  indicative  of  a  fracture,  is 
present  in  a  pretty  large  proportion  of  cases.  It  has  been  observed  by 
me  in  eleven  out  of  twenty-five  cases;  generally  it  did  not  extend 
over  more  than  two  or  three  square  feet  of  surface ;  but  in  one  instance 
it  finally  extended  over  nearly  the  whole  body.  It  is  remarkable, 
however,  that  in  only  four  of  these  eleven  cases  did  the  patients  ex- 
pectorate blood,  and  then  in  a  very  small  quantity,  and  not  until  the 
second  or  third  day. 

Desault  observes  that  emphysema  rarely  succeeds  to  fractures  of 
the  ribs ;  an  observation  which,  as  will  be  seen,  my  experience  does 
not  confirm. 

Treatment. — In  simple  fractures,  where  there  is  no  displacement,  or 
where  the  displacement  is  only  moderate,  the  chest  may  be  inclosed 
with  a  broad  belt  or  band,  as  we  have  already  directed  in  case  of  frac- 
ture of  the  sternum ;  provided  always  that  it  is  not  found  to  increase 
instead  of  diminishing  the  patient's  sufferings.  Some  patients  cannot 
tolerate  this  confinement  at  all;  while  with  a  majority,  although  it  is 
at  first  uncomfortable  and  oppressive,  after  an  hour  or  two  it  affords 
great  relief  from  the  distressing  pain,  and  they  will  not  consent  to 
have  it  removed  even  for  a  moment.  In  nearly  all  cases  of  commi- 
nuted fracture  it  is  inadmissible,  on  account  of  its  tendency  to  force 
the  pieces  inwards. 

Hannay,  of  England,  has  suggested  the  use  of  adhesive  strips  as  a 
substitute  for  the  cotton  or  flannel  band;  the  several  successive  pieces 
being  imbricated  upon  each  other  until  the  whole  chest  is  covered.^ 
The  same  objection  holds  to  this  mode  of  dressing  as  to  a  similar  mode 
of  dressing  a  broken  clavicle,  which  has  been  recently  recommended. 
It  will  certainly  become  loosened  after  a  few  hours,  by  the  slight  but 
uninterrupted  play  of  the  nbs. 

The  forearm  ought  also  to  be  brought  across  the  chest  at  a  right 
angle  with  the  arm,  and  secured  in  this  position  with  a  moderately 
tight  bandage  or  sling,  so  as  to  prevent  any  motion  in  the  pectoral 
muscles. 

As  to  position,  the  patient  generally  prefers  to  sit  up,  or  he  chooses 
a  position  only  partly  reclining  upon  his  back  ;  but  there  is  no  positive 
rule  to  be  observed  in  this  matter,  except  that  such  a  position  shall 
be  chosen  as  shall  prove  most  comfortable  to  the  patient. 

'  American  Journ.  Med.  Sci.,  vol.  xxxix.  p.  198.    From  Lond.  Med.  Gaz.,  Nov. 
1845. 


176      FRACTURES    OF    THE    RIBS    AND    THEIR    CARTILAGES. 

If  the  fragments  are  salient  outwards,  the  fracture  having  been  pro- 
duced by  a  counter  stroke,  they  may  be  reduced  by  pressing  gently 
upon  them  from  without.  If,  on  the  contrary,  the  fragments  are  salient 
inwards,  they  will  be  found,  in  a  great  majority  of  cases,  to  have  re- 
sumed their  positions  spontaneously  or  through  the  natural  actions  of 
respiration ;  but  if  they  have  not,  it  will  be  exceedingly  difficult  to 
restore  them.  Possibly  it  may  be  accomplished  by  pressing  forcibly 
upon  the  front  of  the  chest,  or  upon  the  anterior  extremity  of  the 
broken  rib ;  yet  if  the  fragments  a^e  comminuted,  and  the  ends  are 
much  driven  in,  this  method  will  avail  little  or  nothing.  In  such  cases 
several  surgeons  have  recommended  that  we  should  cut  down  to  the 
bone  and  elevate  the  fragments,  but  Eossi  alone  claims  to  have  actu- 
ally put  the  suggestion  into  practice. 

No  doubt,  if  the  necessit}^  was  urgent,  this  method  might  be  suc- 
cessfully adopted;  or,  instead  of  cutting  down  to  the  broken  rib,  we 
might  even  seize  the  fragment  with  a  hook,  as  suggested  by  Malgaigne, 
or,  what  in  some  cases  might  be  even  more  convenient,  with  a  pair  of 
forceps  constructed  with  long  teeth,  obliquely  set  upon  a  firm  shaft. 
Yet  the  exigency  which  will  demand  a  resort  to  any  of  these  measures 
will  be  exceedingly  rare.  In  gunshot  fractures,  which  are  nearly  all 
compound  and  comminuted,  the  loosened  or  detached  fragments  should 
be  at  once  removed. 

In  no  case  do  I  attach  any  value  or  importance  to  the  advice  given 
by  Petit,  that  we  shall  place  a  compress  upon  the  front  of  the  chest, 
underneath  the  bandage,  in  order  to  reduce  the  fragments,  or  to  retain 
them  in  place  after  reduction.  Lisfranc,  who  advocated  this  method, 
claimed  that  its  advantage  consisted  in  the  increased  length  which 
was  thus  given  to  the  antero-posterior  diameter  of  the  chest,  and  the 
consequent  accumulation  of  pressure  from  the  encircling  band,  in  this 
direction.'  The  mechanical  law  is  no  doubt  correctly  stated,  but  its 
value  in  practice  is  too  inconsiderable  to  deserve  consideration. 

The  emphysema  generally  demands  no  especial  attention,  since  it  is 
usually  too  limited  to  occasion  inconvenience;  and  when  more  exten- 
sive, it  generally  disappears  spontaneously  after  a  few  days,  or  a  few 
weeks  at  most.  The  advice  given  by  some  surgeons,  that  we  ought 
in  these  cases  to  cut  down  to  the  pleural  cavity  so  as  to  allow  the  air 
to  escape  freely  through  the  incision,  seems  thus  far  to  have  rested  its 
reputation  upon  a  more  than  doubtful  theory  rather  than  upon  any 
testimony  of  experience.  Abernethy  alone,  so  far  as  I  know,  has 
actually  made  the  experiment,  and  his  patient  died. 

Dupuytren,  in  the  two  cases  already  alluded  to,  bled  the  patients 
and  applied  resolvent  liquids,  with  rollers ;  he  also  made  incisions 
with  the  lancet  at  various  points  of  the  body,  more  or  less  remote  from 
the  seat  of  fracture,  a  practice,  however,  in  which  he  confesses  he  has 
no  confidence  whatever.     These  patients  both  died. 

Dr.  Stedman,  of  the  Massachusetts  General  Hospital,  has  reported  the 
case  of  a  man  aged  sixty-nine,  of  intemperate  habits,  who,  in  addition  to 
a  fracture  of  one  of  his  ribs,  had  also  a  dislocation  of  the  outer  end  of 

•  Ranking's  Abstract,  vol.  ii.  p.  204,  from  Gaz.  des  Hopitaux,  July  8,  1845. 


FRACTURES    OF    THE    CARTILAGES    OF    THE    RIBS.       177 

the  clavicle.  The  emphysema  commenced  immediately,  and  reached 
its  acme  on  the  twenty-second  day.  At  this  time  it  had  extended 
over  his  whole  body ;  his  eyes  were  closed,  and  he  breathed  with  great 
difficulty;  but  on  the  forty-fifth  day  the  emphysema  had  entirely  dis- 
appeared, and  he  was  dismissed  cured.  The  treatment  consisted 
chiefly  in  the  free  internal  use  of  stimulants,  and  in  the  application  of 
bandages  ;  but  the  bandages  soon  became  disarranged,  and  after  a  few 
days  they  were  entirely  laid  aside.^ 

In  the  case  of  my  own  patient,  where  the  emphysema  was  almost 
equally  extensive,  the  patient  recovered  after  a  few  weeks,  under  the 
use  of  a  simple  diet,  and  without  any  special  medication  whatever. 
Nor  have  I  ever  met  with  a  case  which  demanded  interference  of  any 
kind. 

§  2.  Fractures  of  the  Cartilages  of  the  Ribs. 

Boyer  was  incorrect  when  he  said  that  the  cartilages  of  the  ribs 
could  not  be  broken  until  they  were  ossified.  They  are  often  broken 
when  there  is  no  ossification,  at  the  same  time  that  the  ribs  themselves 
are  broken.  Sometimes  they  are  broken  alone.  Not  unfrequently, 
also,  the  separation  takes  place  at  the  precise  point  of  junction  between 
the  cartilage  and  the  bone. 

Pyper  relates  a  case  in  which  the  sternum  was  broken  in  a  man 
aged  twenty-five  years,  and  also  the  cartilages  of  the  sixth,  seventh, 
and  eighth  ribs  of  the  right  side,  as  was  proven  by  the  autopsy,  yet 
the  cartilages  were  not  ossified.  The  vena  cava  ascendens  was  also 
ruptured  by  the  force  of  the  compression.^  The  reader  is  referred 
also  to  my  own  and  Dr.  Watts'  cases  reported  in  the  chapter  on  Frac- 
tures of  the  Sternum. 

Etiology. — The  causes  are  the  same  as  those  which  produce  fractures 
of  the  ribs,  yet  it  is  generally  understood  that  it  will  require  greater 
force,  and  that  consequently  the  injury  done  to  the  viscera  of  the 
thorax  will  be  more  complicated  and  intense. 

In  the  reports  of  the  Massachusetts  General  Hospital  an  account  is 
given  of  the  case  of  a  man  aged  thirty,  who  was  crushed  by  the  fall 
of  a  heavy  weight  upon  his  body,  and  who  died  after  about  sixty 
hours.  An  examination  after  death  revealed  a  fracture  of  the  car- 
tilages of  the  third  and  fourth  ribs,  with  a  laceration  of  the  intercostal 
muscles  to  such  an  extent  that  a  hernia  of  the  lungs  had  occurred  at 
this  point.  This  hernia  had  been  discovered  and  recognized  by  Dr. 
Warren  soon  after  the  accident  occurred ;  the  protrusion  being  at 
that  time  as  large  as  the  clenched  fist,  and  regularly  rising  and  falling 
with  each  movement  of  respiration.  It  was  accompanied,  also,  with  a 
moderate  emphysema. 

Pathology. — The  fracture  is  clean  and  vertical,  or  transverse ;  never 
irregular  or  oblique.  The  direction  of  the  displacement  varies  as  in 
fractures  of  the  ribs,  but  the  anterior  or  sternal  fragment  is  generally 
found  in  front  of  the  posterior  or  spinal. 

•  Boston  Med.  and  Surg.  Journ.,  vol.  Hi.  p.  316. 

*  Ranking's  Abstract,  vol.  i.  p.  147,  from  the  Lancet,  Oct.  1844. 


178  FEACTUEES  OF  THE  CLAVICLE. 

Union  takes  place  in  these  fractures,  not  through  the  medium  of 
cartilage,  but  of  bone.  Sometimes  the  new  bone  being  deposited  only 
between  the  ends  of  the  fragments,  in  the  form  of  a  thin  plate,  and  at 
other  times  it  is  formed  around  the  fragments  as  well  as  between 
them.  The  latter  of  these  two  processes  has  been  most  frequently 
observed.  The  ensheathing  callus  appears  to  be  supplied  by  the  peri- 
chondrium, while  the  experiments  of  Dr.  Red  fern  render  it  probable 
that  the  intermediate  callus  may  result  from  a  conversion  or  trans- 
formation of  the  adjacent  cartilaginous  surfaces.  Paget  remarks,  also, 
that  the  ossification  extends  to  the  parts  of  the  cartilage  immediately 
adjacent  to  the  fracture. 

I  have  seen  one  example,  in  the  person  of  Hiram  Leech,  set.  38, 
which,  after  the  expiration  of  more  than  one  year,  had  not  united. 
The  fracture  had  occurred  in  the  united  cartilages  of  the  tenth  and 
eleventh  ribs.  The  posterior  fragment  overlapped  the  anterior,  and 
they  played  freely  upon  each  other  at  each  act  of  inspiration  and 
expiration. 

I  do  not  know  that  any  observations  have  been  made  upon  the 
repair  of  these  cartilages  in  very  early  life,  and  it  is  possible  that  the 
process  may  differ  from  this,  which  has  been  described  as  it  has  been 
observed  in  the  adult. 

Treatment. — The  treatment  need  not  differ  from  that  already  recom- 
mended for  fractured  ribs. 


CHAPTER  XVIII. 

FRACTURES  OF  THE  CLAVICLE. 

Foe  the  sake  of  convenience,  I  shall  divide  fractures  of  the  clavicle 
into  those  occurring  through  the  inner,  middle,  and  outer  thirds.  By 
the  "outer  third"  is  meant  all  that  portion  of  the  clavicle  included 
between  its  scapular  extremity  and  the  internal  margin  of  the  conoid 
ligament.  The  remaining  portion  is  intended  to  be  divided  equally 
into  two  separate  thirds.  The  peculiarities  of  these  several  portions, 
in  respect  to  anatomical  relations,  liability  to  fracture,  results,  etc., 
will  explain  the  propriety  of  the  divisions. 

Causes. — If  we  except  gunshot  fractures,  the  clavicle  is  broken,  in 
a  large  majority  of  cases,  by  a  counter-stroke,  such  as  a  fall,  or  a  blow 
upon  the  extremity  of  the  shoulder. 

Occasionally  it  is  broken  by  a  direct  stroke,  as  when  a  blow  aimed 
at  the  head  is  received  upon  the  shoulder ;  it  is  broken  sometimes  by 
the  recoil  of  an  overloaded  gun,  especially  when  the  person  lies  upon 
the  ground,  with  the  butt  of  the  gun  resting  against  the  clavicle. 

Gibson  has  seen  a  case  in  which  it  was  broken  in  a  child  at  birth, 


FRACTURES    OF    THE    CLAVICLE.  179 

by  an  ignorant  midwife  pulling  at  the  arm/  and  Dr.  Atkinson  has  re- 
ported an  example  of  intra-uterine  fracture  of  the  cUivicle.'- 

I  have  once  seen  the  clavicle  broken  by  muscular  action  alone.  A 
large,  well-built,  and  healthy  man,  aged  thirty-seven,  standing  upon 
the  ground,  attempted  to  secure  the  braces  of  his  carriage-top  with 
his  right  arm,  when  he  felt  a  sudden  snap,  as  if  something  about  his 
shoulder  had  given  way.  He  did  not,  however,  suspect  the  nature  of 
the  injury,  and  did  not  consult  any  surgeon  until  eight  days  after,  at 
which  time  I  found  the  right  clavicle  broken  near  its  centre,  but 
rather  nearer  the  sternal  than  scapular  extremity.  The  fragments 
were  but  slightly,  if  at  all,  displaced,  but  motion  and  crepitus  at  the 
point  of  fracture  were  distinct.  The  usual  node-like  swelling  was 
also  present,  indicating  the  existence  of  a  considerable  amount  of  en- 
sheathing  callus.  He  had  been  unable  to  raise  the  arm  to  a  right 
angle  with  the  body  since  it  was  broken,  but  he  had  suffered  no  other 
inconvenience  from  it. 

A  similar  case  is  reported  in  the  number  for  January,  1843,  of  the 
American  Journal  of  Medical  Sciences,  copied  from  the  Revista  Medica. 
The  subject  of  this  case  was  a  colonel  of  cavalry,  about  sixty  years  of 
age.  In  mounting  his  horse,  he  experienced  a  sensation  as  if  some- 
thing had  broken,  followed  by  acute  pain  in  his  left  shoulder,  and,  on 
examination,  it  was  found  that  the  clavicle  was  fractured  in  the  mid- 
dle. The  health  of  this  gentleman  had  been  impaired,  it  is  further 
stated,  by  repeated  attacks  of  syphilis. 

Malgaigne  has  recorded  three  other  examples  of  fracture  of  this 
bone  from  muscular  action ;  and  Parker  saw  a  case  which  was  pro- 
duced by  striking  at  a  dog  with  a  whip  ;  the  bone  had  been  previously 
somewhat  diseased,  yet  it  united  favorably.^ 

Of  these  six  cases,  five  occurred  on  the  right  side,  and  always  near 
the  middle  of  the  bone,  if  we  except  one  case  reported  by  Malgaigne, 
in  which  the  point  of  fracture  is  not  mentioned.  In  neither  case  did 
the  fragments  become  displaced,  only  as  they  were  found,  in  some  of 
the  examples,  inclined  slightly  forwards. 

Pathology. — It  has  already  been  observed,  in  speaking  of  partial 
fractures,  that  this  bone  suffers  an  incomplete  fracture  more  often 
than  any  other,  and  that  in  such  cases  the  lesion  occurs  generally  in 
the  middle  third,  or  rather  to  the  sternal  side  of  the  centre,  and  in  a 
direction  nearly  or  quite  transverse.  They  are  not  usually  accom- 
panied with  much  displacement;  but  if  a  displacement  exists,  it  is  a 
slight  forward  inclination  of  the  fragments. 

Fractures  which  are  complete  occur  mostly  after  the  bones  have 
become  firm  and  unyielding.  They  are  also  generally  oblique,  seldom 
comminuted,  still  more  rarely  compound.  The  point  of  the  clavicle 
at  which  a  complete  fracture  usually  occurs  is  at  or  near  the  outer 
end  of  the  middle  third,  and  a  little  to  the  sternal  side  of  the  coraco- 
clavicular  ligaments,  near  where  the  trapezius  and  deltoid  cease  their 
attachments.     It  might  be  more  exact  to  say  that  the  fracture  extends 

'  Gibson,  Principles  of  Surg.,  sixth  ed.,  vol.  i.  p.  272. 

2  Atkinson,  Bost.  Med.  and  Surg.  Journ.,  July  26,  1860. 

3  Parker,  N.  Y.  Journ.  Med.,  July,  1852. 


180 


FRACTUEES    OF    THE    CLAVICLE, 


from  tliis  point  downwards  and  inwards,  toward  the  sternum,  em- 
bracing one  inch  or  less  of  its  entire  length.  In  some  cases  the  obli- 
quity is  greater,  and  the  amount  of  bone  involved  is  much  more 
considerable. 

Why  the  bone  should  break  more  frequently  at  this  point,  espe- 
cially in  the  adult  and  in  the  male,  it  is  not  difficult  to  understand. 
It  is  smaller  here  than  elsewhere,  and  less  supported  by  muscular  and 
ligamentous  attachments.  At  this  point,  also,  the  axis  of  the  bone 
begins  pretty  abruptly  to  curve  forwards,  and  more  abruptly  in  the 
adult  and  male  than  in  the  child  and  female.  When,  therefore,  the 
clavicle  is  broken,  as  it  usually  is,  by  a  counter-stroke,  the  force  of 
the  blow,  conveyed  from  the  shoulder  through  the  outer  portion  of  the 
bone,  is  suddenly  arrested,  and  expends  itself  upon  the  point  where 
the  direction  of  the  axis  is  changed. 

In  a  record  of  one  hundred  and  five  fractures,  including  partial  and 
comminuted,  and  not  including  gunshot  fractures,  eighty -eight  have 

occurred    through     the     middle 
Fig.  40.  third  ;  and,  with  the  exception  of 

the  partial  fractures,  the  fracture 
has  in  nearly  all  of  the  cases 
taken  place  near  the  outer  end  of 
this  third.  Four  have  occurred 
through  the  inner  third,  three  of 
"which  were  within  one  inch  of  the 
sternum  ;  and  thirteen  through 
the  outer  third. 

A  more  practical  analysis  can 
be  based,  however,  upon  the  point 
of  fracture  with  reference  to  its 
cause;  and  I  have  never,  but 
once,  seen  a  complete  fracture  of 
this  bone  produced  clearly  by  a 
counter-stroke,  which  was  not 
near  the  outer  end  of  the  middle 
third. 

When  the  fracture  is  at  this 
point,  or  in  any  portion  of  the 
middle  third,  the  direction  of  the 
displacement  is  almost  uniformly 
the  same.  The  sternal  fragment 
is  slightly  lifted  by  the  action  of 
the  clavicular  portion  of  the  sterno-cleido-mastoid  muscle,  not- 
withstanding the  resistance  of  the  rhomboid  ligament,  and  the  sub- 
clavian muscle.  On  the  other  hand,  the  acromial  fragment  is 
dragged  downwards  by  the  weight  of  the  arm,  aided  by  the  con- 
joined action  of  a  portion  of  the  pectoralis  major  and  the  latissi- 
mus  dorsi,  feebly  resisted  by  the  trapezius  and  other  muscles  from 
above;  by  the  action  of  the  same  muscles,  aided  by  the  pectoralis 
minor,  and  perhaps  by  some  portion  of  the  subclavius,  it  is  drawn 
toward  the  body,  diminishing  thereby  the  axillary  space ;  while  by 
the  preponderating  strength  of  the  pectoralis  major  and  minor,  the 


Complete  oblique  fracture  of  clavicle. 


FRACTTJRES    OF    THE    CLAVICLE.  ISI 

acromial  end  of  the  fragment,  with  the  shoulder,  is  drawn  forwards  • 
the  sternal  end  of  the  same  fragment  being  rather  displaced  back- 
wards, and  at  the  same  time  resting  at  a  point  somewhat  elevated 
above  the  acromial  end. 

Desault  has  recorded  one  example  of  an  overlapping  by  the  eleva- 
tion of  the  acromial  fragment  over  the  sternal  ;^  and  Bichat  remarks 
that  Hippocrates  speaks  of  the  phenomenon  as  a  thing  which  was 
familiar  to  him.  Sjme  has  mentioned  a  case  of  this  kind  which  he 
had  seen.^  Gueretin,  Malgaigne,^  and  Stephen  Smith  have  each  re- 
ported an  example.'*  In  Stephen  Smith's  case  the  fracture  occurred 
in  a  man  thirty-eight  years  old.  The  bone  was  broken  through  the 
outer  third,  and  transversely.  He  was  treated  at  the  Bellevue  Hos- 
pital, but  the  overlapping,  to  the  extent  of  one  inch,  remained  after 
the  cure  was  completed. 

In  nearly  all  the  cases  of  oblique  fractures  occurring  through  the 
middle  third  there  follows  im.mediately  an  overlapping,  varying  from 
one-quarter  of  an  inch  to  an  inch,  and  sometimes,  though  very  rarely, 
exceeding  this.  There  is  a  specimen  in  the  Dupuytren  Museum,  in 
which  the  shortening  equals  one-third  of  its  entire  length. 

Transverse  fractures,  wherever  they  may  occur,  are  not  so  constantly 
found  displaced,  at  least  in  the  direction  of  the  axis  of  the  bone,  as  the 
following  examples  will  illustrate: — 

An  old  lady,  aged  eighty  years,  fell  down  a  flight  of  stairs,  break- 
ing the  right  clavicle  transversely,  about  one  inch  from  the  sternum. 
I  saw  her,  with  Dr.  Trowbridge,  on  the  day  following  the  accident. 
Motion  and  crepitus  were  distinct,  but  there  was  scarcely  any  dis- 
placement. No  dressings  were  applied,  but  she  was  directed  to  keep 
quiet  in  bed,  and  upon  her  back.  In  the  usual  time  the  fragments 
had  united,  without  deformity. 

A  man,  about  forty  3'ears  old,  fell  backwards  from  a  wagon,  break- 
ing the  collar-bone  near  the  middle.  The  fragments  were  movable, 
but  not  displaced.  He  was  treated  successfully  and  without  any  re- 
sulting deformity,  by  simple  confinement  in  the  recumbent  posture 
during  a  few  days,  and  after  this  by  suspending  the  arm  in  a  sling, 
while  he  was  permitted  to  walk  about. 

A  young  man,  aged  twenty-six,  fell  while  wrestling  and  broke  the 
clavicle  at  the  outer  end  of  the  middle  third.  There  was  some  dis- 
placement at  first,  but  the  fragments  being  reduced,  were  found  to  sup- 
port themselves,  A  cross,  secured  with  straps,  was  applied  to  the 
back,  and  on  the  twenty-eighth  day  the  union  was  complete,  and  with- 
out deformity. 

A  child,  aged  three  years,  fell  about  six  feet,  striking  upon  his 
shoulder.  He  was  sent  to  me  on  the  same  day,  by  Dr.  G.  Burwell.  I 
found  the  left  clavicle  broken  off'  completely,  about  one  inch  from  its 
scapular  end.  Crepitus  and  motion  were  distinct,  but  the  I'raginents 
were  not  displaced.  The  arm  was  placed  in  a  sling,  and  on  the  seventh 
day  both  motion  and  crepitus  had  ceased.  The  cure  was  accomplished 
without  any  degree  of  displacement. 

'  Desault  on  Frac,  op.  cit.,  p.  16.       2  Amer.  Joum.  Med.  Sci.,  vol.  xvii.  p.  251. 
3  Malgaigne,  p.  4G1.  *  N.  Y.  Journ.  of  Med.,  May,  1857. 


182  FRACTUKES    OF    THE    CLAVICLE. 

The  example  of  a  fracture  from  muscular  action,  already  mentioned 
as  having  been  seen  bj  me,  was  also  probably  transverse,  and  union 
has  occurred  without  treatment  and  without  displacement. 

Stephen  Smith,  of  New  York,  has  met  with  two  examples  of  trans- 
verse fractures  without  displacement,  in  a  hospital  record  of  eleven 
cases,  Bichat  says  Desault  has  frequently  observed  the  same,  it 
having  been  seen  three  times  at  Hotel  Dieu,  in  the  course  of  the  year 
lltil}  Desault  thinks,  also,  that  sometimes  the  fracture,  taking  place 
obliquely  upwards  and  inwards,  the  usual  form  of  displacement  is 
prevented,  and  apposition  is  preserved. 

If  the  fracture  is  near  the  sternum,  and  within  the  fibres  of  the 
costo-clavicular  ligaments,  as  in  the  case  of  the  old  lady  just  cited,  the 
displacement  is  inconsiderable.  I  have  seen  one  other  similar  case,  in 
an  adult  also.  Lonsdale  mentions  a  case,  in  a  child  three  years  old, 
which  came  under  his  observation  in  Middlesex  Hospital,'^  which  he 
regarded  as  a  separation  of  the  epiphysis ;  this  bone,  however,  has  no 
epiphysis,  properly  speaking,  being  formed  entire  from  a  single  point 
of  ossification.  Malgaigne  mentions  two  other  examples,  in  one  of 
which  the  fracture  was  so  near  the  sternum  that  it  was  difficult  to  say 
whether  it  was  not  a  partial  dislocation.  The  displacement  was  only 
trivial.^  But  the  only  two  specimens  contained  in  the  Dupuytren 
Museum  offer  a  considerable  displacement,  and  in  both  the  external 
fragment  is  thrown  downwards  and  forwards. 

March  22,  1865,  I  presented  to  the  New  York  Pathological  Society 
a  similar  case,  obtained  from  a  patient  in  Bellevue  Hospital.  The 
man  from  whom  this  specimen  was  taken  was  forty-five  years  old,  and 
the  fracture,  occasianed  by  a  fall  upon  the  shoulder,  extended  from  the 
sterno-clavicular  articulation  upwards  and  outwards  one  inch  and  a 
half.  The  fragments  were  overlapped  three  quarters  of  an  inch,  and 
were  firmly  united.  The  character  of  the  accident  was  not  recognized 
until  alter  death.  The  specimen  is  now  in  the  museum  of  the  Bellevue 
Hospital. 

With  regard  to  the  amount  of  displacement  usually  attendant  upon 
fractures  near  the  outer  end  of  the  bone,  surgical  writers  have  gene- 
rally united  in  declaring  that  it  was  in  a  majority  of  cases  very  incon- 
siderable, while  some  have  even  affirmed  that  there  would  be  found  no 
displacement  whatever  ;  neither  of  which  opinions,  according  to  the 
observations  of  Robert  Smith,  of  Dublin,  is  strictly  correct.  He  has 
examined  eight  specimens  of  fracture  of  the  outer  extremity  of  the 
clavicle,  contained  in  the  museum  of  the  Richmond  Hospital  School 
of  Medicine ;  three  of  which  were  broken  between  the  conoid  and 
trapezoid  ligaments,  and  are  united  with  very  little  displacement, 
while  the  remaining  five,  broken  beyond  the  trapezoid  ligament,  pre- 
sent a  very  marked  deformity. 

The  following  is  a  summary  of  the  conclusions  to  which  he  has 
arrived : — 

"When  the  clavicle  is  broken  between  the  two  fasciculi  of  the 

'  Desault  on  Fractures,  op.  cit.,  p.  15.  *  Lonsdale  on  Fractures,  p.  206. 

*  Malgaigne,  op.  cit.,  p.  491. 


FRACTUEES    OF    THE    CLAVICLE.  183 

coraco-clavicular  ligament,  there  is  seldom  any  displacement  of  either 
fragment,  and  always  much  less  than  in  fracture  of  any  other  portion 
of  the  bone.  When  displacement  does  occur,  it  is  usually  limited  to 
a  slight  alteration  in  the  direction  of  the  bone,  by  which  the  natural 
convexity  of  this  portion  of  the  clavicle  is  increased, 

"The  explanation  of  which  facts  is  found  in  the  attachments  of  the 
ligaments  from  below  to  the  two  fragments ;  and  in  the  action  of  the 
trapezius  from  above,  by  which  they  are  antagonized, 

"But  the  case  is  very  different  when  the  bone  is  broken  external 
to  the  trapezoid  ligament.  Here  the  coraco-clavicular  ligaments  can 
have  no  direct  influence  upon  the  outer  fragment,  which  is  displaced 
now  partly  by  muscular  action,  and  partly  by 
the  weight  of  the  arm,  the  sternal  end  of  the 
outer  fragment  being  drawn  upwards  by  the 
clavicular  portion  of  the  trapezius,  while,  by 
the  action  of  the  muscles  passing  from  the  chest, 
the  entire  outer  fragment  is  drawn  forwards  and 
inwards,  so  as  to  bring  sometimes  its  broken  sur- 
face into  contact  with  the  anterior  surface  of  the    ,.  ^"'"T  ^^''f''''''''^''''^ 

...  .  ligament.     United. 

inner  fragment,  and  piacmg  it  neariy  at  right 

angles  with  this  fragment,  in  which  position  it  is  generally  united. 
The  displacement  in  this  direction,  rather  than  any  degree  of  over- 
lapping, explains  also  the  shortening  which  existed  in  all  of  these 
cases,  varying  in  the  different  specimens  from  half  an  inch  to  one 
inch,  and  averaging  about  three-quarters  of  an  inch." 

Such  are  the  views  of  Mr.  Smith,  and  I  see  no  reason  to  call  in 
question  their  correctness.  In  ray  own  experience,  a  fracture  occur- 
ring in  a  child  three  years  old,  within  one  inch  of  the  acromial  end, 
probably  between  the  ligaments,  was  never  displaced  at  all;  a  second, 
occurring  somewhere  in  the  outer  third,  presented,  after  many  years, 
no  displacement.  Two  recent  cases  were  displaced  each  one-quarter 
of  an  inch,  and  one  old  case,  half  an  inch ;  these  three  latter  cases 
occurred  in  adults,  and  always  within  an  inch  of  the  acromial  end  of 
the  bone.  In  one  of  these  last  examples,  the  inner  fragment  was 
rather  behind  than  above  the  outer  fragment. 

But  it  would  be  unsafe  to  draw  conclusions  from  an  experience 
which  is  confined  entirely  to  living  examples,  and  in  which  no  dissec- 
tions have  been  made,  to  verify  the  exact  point  of  fracture,  or  the 
precise  amount  and  character  of  the  displacement.  So  far  as  they  go, 
however,  they  seem  to  me  to  confirm  the  general  correctness  of  the 
observations  made  by  Robert  Smith. 

It  has  happened  to  me  only  six  times  to  meet  with  a  comminuted 
fracture  of  the  clavicle,  except  in  cases  of  gunshot  injuries,  all  of  which 
fractures  occurred  through  some  portion  of  the  middle  third  of  the 
bone ;  the  intercepted  fragments  being  from  one  inch  to  one  inch  and 
a  half  in  length,  and  lying  obliquely,  or,  as  in  one  case  observed  by 
me,  at  nearly  a  right  angle  with  the  main  fragments. 

I  have  never  seen  a  compound  fracture  of  this  bone  except  as  the 
result  of  a  gunshot  injury,  although,  in  many  cases,  the  sharp  point 
of  an  oblique  fracture  has  seemed  just  ready  to  penetrate  the  skin. 


184 


FRACTURES    OF    THE    CLAVICLE. 


One  case  is  reported  as  having  been  presented  at  St.  Bartholomew's 
Hospital.  It  occurred  in  a  boy  fourteen  years  old,  and  was  produced 
by  his  having  been  drawn  into  some  machinery  while  it  was  in  motion.^ 
Two  similar  cases  are  reported  from  the  New  York  Hospital,  as  hav- 
ing been  observed  during  the  last  ten  years.  The  whole  number  of 
examples  of  fracture  of  the  clavicle  during  this  period  was  191.^ 

Lente  also  mentions  a  case,  seen  by  himself,  occasioned  by  the  fall 
of  a  derrick  upon  the  shoulder.  The  patient,  twenty-four  years  old, 
was  admitted  into  the  New  York  Hospital  in  August,  1848.  The  left 
clavicle  was  broken  at  about  its  middle,  and  a  large  wound  in  the 
integuments  communicated  with  the  fracture.  The  fragments  united 
firmly  in  about  six  weeks,  after  several  pieces  of  bone  had  been  dis- 
charged from  the  wound.^ 

A  double  fracture,  or  a  simultaneous  fracture  occurring  in  both 
clavicles,  seldom  occurs.  I  have  recorded  two  cases  {four  fractures, 
three  of  which  are  incomplete),  both  occurring  in  young  boys.* 

Malgaigne  says  it  has  only  happened  to  him  to  see  it  once  in  2858 
cases,  at  the  Hotel  Dieu,  and  he  can  recollect  only  five  other  examples. 
And  of  158  cases  of  broken  clavicles  reported  from  the  New  York 
Hospital,  it  is  stated  to  liave  occurred  in  only  four.     These  gentlemen 

however,  only  report  hospital 
cases,  and  they  have  reference, 
doubtless,  to  complete  fractures  ; 
while  double  fractures,  accord- 
ing to  my  experience,  occur  more 
often  in  children  than  in  adults, 
and  are  of  the  character  of  partial 
fractures,  without  usually  much 
displacement;  which  facts,  if  sus- 
tained by  subsequent  observa- 
tions, would  sufficiently  explain 
their  infrequency  in  hospital,  and 
their  relative  frequency  in  pri- 
vate experience. 

Symptoms. — In  all  cases  of 
complete  fracture  with  displace- 
ment, no  difficulty  will  be  ex- 
perienced in  deciding  upon  the 
nature  of  the  injury. 

The  patient  is  found  generally 
leaning  toward  the  injured  side, 
while  the  opposite  hand  sustains  the  elbow  of  the  same  side,  to  pre- 
vent its  dragging  downwards. 

The  shoulder  falls  downwards,  forwards,  and  inwards ;  while,  at 
the  same  time,  the  line  of  the  bone  is  interrupted  by  the  sharp  and 
projecting  point  of  the  sternal  fragment. 

'  London  Med.  Gaz.,  vol.  ii.  p.  382. 

2  New  York  Med.  Times,  March  16,  1861. 

3  Lente,  N.  Y.  .Jonrn.  of  Med.,  July,  1850. 
♦  Rep.  on  Def.  after  Frac,  Cases  5,  6,  10. 


Complete    Fracture. — Oblique;      at    junction    of 
outer  and  middle  thirds.     (From  nature.) 


FRACTUEES    OF    THE    CLAVICLE.  185 

If  the  fracture  is  the  result  of  a  direct  blow,  a  swelling  and  discolor- 
ation may  be  seen  at  the  seat  of  fracture;  but  if  it  is  the  result  of 
a  counter-stroke,  we  must  look  to  the  top  or  point  of  the  shoulder  for 
the  signs  of  a  contusion. 

The  patient  also  experiences  pain  when  an  attempt  is  made  to  raise 
the  arm  at  a  right  angle  with  the  body,  and  especially  in  attempting 
to  carry  the  arm  across  the  body,  by  which  the  ends  of  the  broken 
clavicle  are  driven  into  the  flesh.  In  two  cases  (Cases  19  and  50  of 
my  Report  on  Deformities)  of  oblique  fracture,  accompanied  with  dis- 
placement, occurring  in  the  middle  third  of  the  bone,  I  have  particu- 
larly noticed  that  the  patients  could  easily  lift  the  hands  to  the  head, 
and  in  one  of  these  cases  the  patient,  a  boy  fourteen  years  old,  raised 
his  arm  perpendicularly  over  his  head.  Such  exceptions  are  not  very 
uncommon. 

Crepitus  can  be  detected  sometimes  by  simply  pressing  down  the 
sternal  fragments,  but  it  is  almost  always  present  when  we  draw  the 
shoulders  forcibly  back,  so  as  to  bring  the  broken  fragments  into  more 
perfect  contact. 

If  there  is  no  displacement,  still  crepitus  may  generally  be  discovered 
by  grasping  the  bone  between  the  thumb  and  fingers,  and  moving  it 
gently  up  and  down,  or  by  slight  pressure  upon  the  point  of  fracture. 

When  the  fracture  occurs  close  to  the  acromial  extremity,  external 
to  the  coraco-clavicular  ligaments,  although,  according  to  Robert 
Smith,  there  is  usually  considerable  derangement,  yet  it  is  not  accom- 
panied with  a  corresponding  amount  of  external  deformity,  and  its 
diagnosis  will  require,  therefore,  more  care  and  attention  on  the  part 
of  the  surgeon. 

Prognosis  in  this  fracture  deserves  especial  attention.  In  no  other 
bone,  except  the  femur,  does  a  shortening  so  uniformly  result.  Of 
seventy-two  complete  fractures  only  sixteen  united  without  shortening ; 
and  of  twenty-seven  simple,  oblique,  complete  fractures,  which  occurred 
at  or  near  the  outer  end  of  the  middle  third,  only  one  united  without 
shortening  (Case  46  of  my  Report),  and  in  this  case  the  patient  was 
but  fifteen  years  old,  and  the  fragments  were  never  much  displaced ; 
nor  can  I  say  that  the  treatment — a  board  across  the  back,  after  the 
manner  of  Keckerley — had  anything  to  do  with  the  result.  Six  cases 
of  complete  transverse  fracture,  occurring  at  the  same  point,  united 
without  shortening. 

The  shortening  varies  from  one-quarter  of  an  inch  to  one  inch  or 
more,  and  the  fragments  are  almost  always,  especially  when  the  frac- 
ture is  through  the  middle  third,  found  lying  in  the  position  in  which 
we  have  described  them  to  be  at  the  first — the  outer  end  of  the  inner 
fragment  being  above,  and  often  a  little  in  front  of,  the  outer;  some- 
times, especially  inlean  persons,  and  when  the  fracture  is  very  oblique, 
presenting  a  sharp  and  unseemly  projection. 

The  greatest  amount  of  shortening  is  generally  found  in  those  frac- 
tures which  occur  through  the  middle  third ;  in  fractures  near  the 
sternal  end  thwe  is  usually  very  little  permanent  displacement ;  the 
same  is  true  when  the  fracture  is  at  the  acromial  end,  and  between 
the  coraco-clavicular  ligaments,  as  the  observations  of  Robert  Smith, 
IB 


186 


FEACTUEES    OF    THE    CLAVICLE. 


already  quoted,  have  sufficiently  established ;  but  if  the  fracture  is 
beyond  these  ligaments,  the  final  displacement  and  deformity  may  be 
very  great. 

The  presence  of  a  small  amount  of  ensheathing  callus  soon  after 
the  cure  is  completed,  sometimes  increases  the  deformity.  It  is  rarely 
seen  to  encircle  the  bone  completely,  and  occasionally  it  appears  to 
be  most  abundant  in  the  direction  of  the  salient  points  of  the  fracture, 
that  is,  above  and  below;  so  that,  unless  the  examination  is  made  with 
care,  the  projecting  points  of  callus  which  remain,  sometimes  after 
many  years,  may  be  easily  mistaken  for  an  intercepted  fragment  turned 
at  right  angles  to  the  axis  of  the  bone, 

Eobert  Smith  has  observed,  also,  that  in  cases  of  fracture  external 
to  the  conoid  ligament,  osseous  matter  is  freely  formed  upon  the  under 
surface  of  each  fragment,  but  there  is  seldom  any  deposited  upon  the 
upper  surface  of  either.  These  osseous  growths,  occupying  the  situa- 
tion of  the  coraco-clavicular  ligaments,  frequently  prolong  themselves 
as  far  as  the  coracoid  process,  and  in  some  cases  to  the  notch  of  the 
scapula.  Still  less  frequently  these  osteophytes  become  fused  with 
the  coracoid  process,  and  a  true  anchylosis  exists. 

In  comminuted  fractures  the  intercepted  fragments  generally  fall  off 
from  the  line  of  the  other  fragments,  and  cannot  easily  be  restored. 

The  clavicle  being  a  spongy  and  vascular  bone,  usually  unites  with 
great  rapidity,  generally  within  twenty  days.  In  the  fourth  example 
of  transverse  fracture  already  mentioned  as  having  been  seen  by  me, 
the  union  seemed  to  be  tolerably  firm  in  seven  days.    Wallace  reports 

one  case  from  the  Pennsylvania 
Hospital,  which  was  cured  in  eight 
days,  and  another  in  nine  days.^ 
Velpeau  says  the  clavicle  will  unite 
in  from  fifteen  to  twenty-five  days; 
Benjamin  Bell,  in  fourteen ;  Stephen 
Smith  has  seen  it  firm  in  fifteen 
days. 

Whatever  may  be  the  degree  of 
displacement,  or  the  condition  of  the 
system,  unless  in  a  case  of  gunshot 
fracture,  it  is  very  seldom  that  it 
refuses  to  unite  altogether,  or  that 
the  union  is  ligamentous;  and  in 
the  few  cases  found  upon  record  of 
a  ligamentous  union,  the  functions 
of  the  arm  do  not  seem  to  have 
sufi'ered  any  serious  ultimate  in- 
jury, as  the  following  example  will 
illustrate: — 

Edmund  Nugent,  a  stout  Irish  laborer,  twenty-five  years  old,  was 
received  into  the  Buftalo  Hospital  of  the  Sisters  of  Charity,  in  March, 
1854.     Several  years  before,  he  fell  from  a  horse  and  broke  his  left 


CoMMiscTED  Fracture. — United.    (From  na- 
ture.) 


'  Am.  Journ.  Med.  Sci.,  a'oI.  xvi.  p.  115. 


FRACTURES    OF    THE    CLAVICLE.  1ST 

clavicle,  at  the  outer  end  of  the  middle  third.  This  was  near  Cork, 
in  Ireland;  and,  without  consulting  any  surgeon  or  "handy  man,"  he 
continued  at  work,  holding  the  tail  of  the  plough,  nor  from  that  day 
forward  did  he  employ  a  surgeon,  or  dress  his  arm,  or  cease  from  his 
work. 

The  clavicle  presented  the  same  deformity  which  many  other  simi- 
lar fractures  present  after  what  is  usually  termed  successful  treatment, 
except  that  it  is  not  united  by  bone.  The  outer  end  of  the  inner  frag- 
ment rode  upon  the  inner  end  of  the  outer  fragment  half  an  inch.  The 
ligament  uniting  the  two  extremities  was  so  long  and  firm  that  it  could 
be  distinctly  felt,  and  the  fragments  moved  upon  each  other  with 
great  freedom. 

In  order  that  we  might  determine  the  amount  of  injury  which  he 
had  suffered  from  the  ligamentous  union,  we  directed  him  to  lift  weights 
placed  on  a  table  before  him,  while  he  was  seated  upon  a  chair.  We 
ascertained  from  this  experiment  that  with  his  left  arm  he  could  lift 
as  much,  within  three  ounces,  as  he  could  with  his  right,  and  he  was 
not  himself  conscious  of  any  difference.  The  muscles  of  the  left  arm 
seemed  as  well  developed  as  those  of  the  right. 

Chelius  also  refers  to  two  cases  mentioned  by  Gurdy  and  Yelpeau, 
in  which,  although  an  artificial  joint  remained,  the  use  of  the  limb 
was  but  little  impaired.^ 

In  a  case  of  compound  and  comminuted  gunshot  fracture  reported 
by  Ayres,  of  New  York,  the  recovery  was  remarkable.  The  man  was 
sixty-two  years  old,  and  in  excellent  health,  when  the  injury  was  re- 
ceived. The  clavicle  was  so  extensively  comminuted  that  before  the 
wound  closed  over  one-third  of  the  bone  had  escaped,  and  yet  at  the 
end  of  one  year  from  the  time  of  the  accident  the  shoulder  was  per- 
fectly symmetrical  with  its  fellow,  without  drooping  or  falling  for- 
wards. Dr.  Ayres  thinks  that  all  of  the  clavicle  which  was  lost  has 
been  reproduced. 

A  partial  paralysis,  with  atrophy  of  the  muscles  of  the  arm,  accom- 
panied, also,  with  more  or  less  rigidity  and  contraction  of  the  muscles 
both  of  the  arm  and  forearm,  is,  according  to  my  observation,  a  more 
frequent  result  of  these  fractures. 

Mr.  Earle  has  recorded  a  case  of  comminuted  fracture  of  the  clavicle, 
in  which  the  nerves  converging  to  form  the  axillary  plexus  were  so 
much  injured  that  paralysis  of  the  arm  ensued;  and  it  was  noticed  as 
an  interesting  fact,  that  the  patient  could  not  afterwards  put  her  hand 
into  even  moderately  warm  water  without  the  effects  of  a  scald  being 
produced,  characterized  by  vesications,  redness,  etc.^ 

Desault  saw  a  case  at  Hotel  Dieu,  in  which,  although  the  clavicle 
was  not  broken,  the  force  of  the  blow  upon  the  clavicle  was  sufficient 
to  produce  a  severe  concussion  of  the  brachial  plexus,  and  paralysis 
of  the  arm.  A  timber  had  fallen  from  a  building,  striking  upon  the 
external  part  of  the  left  clavicle.  A  considerable  wound,  followed  by 
swelling,  pointed  out  the  place  on  which  the  blow  had  been  received. 

'  Chelius,  Amer.  od.,  vol.  i.  p.  G03. 

2  S.  Cooper's  First  Lines,  fourth  Amer.  ed.,  vol.  ii.  p.  323.. 


188  FRACTURES    OF    THE    CLAVICLE. 

No  apparatus  was  applied,  and  on  the  third  day  a  numbness  and  par- 
tial loss  of  the  power  of  motion  occurred  in  the  arm  of  the  affected 
side.  Soon  afterward  an  insensibility  came  on,  and  by  the  seventh 
day  the  paralysis  of  the  arm  was  complete.  It  was  not  until  after  a 
tedious  treatment  that  the  limb  recovered  in  part  its  original  strength.^ 

In  Case  23  of  my  report  to  the  American  Medical  Association,  which 
was  followed  by  paralysis  of  the  opposite  arm,  and  spinal  curvature, 
these  results  were  probably  due  to  some  injury  of  the  back  received 
at  the  time  of  the  accident;  but  one  cannot  avoid  a  suspicion  that  the 
apparatus,  Brasdor's  jacket,  contributed  somewhat  to  the  unfortunate 
result.  No  axillary  pad  was  employed,  but  the  straps  over  each 
shoulder  were  buckled  so  tight  that  he  was  compelled  to  incline  his 
head  constantly  to  the  right  side.  He  was  unable  to  lie  down,  and 
could  only  recline  in  a  half-sitting  posture.  This  treatment  was  con- 
tinued four  weeks ;  and  two  months  after  its  removal  the  paralysis 
and  spinal  distortion  commenced. 

In  Case  38,  also,  of  the  same  report,  a  comminuted  fracture,  paralysis 
with  contraction  of  the  muscles  extending  to  the  wrist  and  fingers  ex- 
isted, but  whether  it  was  due  to  the  severity  of  the  original  injury  or 
to  the  treatment,  could  not  be  satisfactorily  ascertained, 

Gibson  relates  a  remarkable  instance  of  this  kind,  A  young  man 
was  struck  on  the  clavicle  by  the  falling  limb  of  a  tree,  breaking  it  into 
numerous  pieces,  and  bruising  the  parts  so  severely  as  to  give  rise  to 
violent  inflammation,  "The  iragments  had  been  driven  behind  and* 
beneath  the  level  of  the  first  rib,  and  so  compressed  the  plexus  of 
nerves  as  to  wedge  them  into  each  other,  and  by  the  subsequent  in- 
flammation to  blend  them  inseparably  together.  Complete  paralysis 
and  atrophy  of  the  whole  arm  ensued,  and  the  patient's  object  in  visit- 
ing Philadelphia  was  to  submit  to  an  operation,  in  hopes  of  elevating 
the  clavicle  to  its  natural  height,  and  taking  oft"  pressure  from  the 
nerves,"  Dr,  Gibson,  however,  did  not  believe  that  the  prospect  of 
success  was  sufficient  to  warrant  the  operation,  and  the  young  man 
"was  sent  home.^ 

It  will  not  do  to  deny,  therefore,  the  possibility  of  a  paralysis  as 
resulting  from  a  concussion  of  the  axillary  nerves,  produced  by  a  blow 
upon  the  clavicle,  nor  of  a  paralysis  resulting  from  a  direct  injury  in- 
flicted by  the  points  of  the  fragments  upon  this  plexus  in  certain  very 
badly  comminuted  fractures;  but  it  is  certain  that  these  conditions 
will  not  satisfactorily  explain  all  of  the  examples  in  which  paralysis 
has  followed  simple  fractures.  In  some  cases  it  is  no  doubt  due  rather 
to  the  injudicious  mode  of  using  an  axillary  pad,  by  means  of  which 
the  arm  is  converted  into  a  powerful  lever,  and  thus  the  brachial 
nerves  are  made  to  suffer  from  compression  along  the  inner  side  of  the 
arm  itself.  In  short,  it  must  be  confessed  that  it  is  sometimes  due  to 
the  treatment  alone,  and  not  to  the  original  injury, 

Parker,  of  New  York,  in  a  note  to  the  edition  of  S,  Cooper's  Sur- 
gery, just  quoted,  declares  that  he  has  seen  one  patient  who  had  lost 

'  Dcsault  on  Frac.  and  Disloc,  Amer.  ecL,  p.  14,  1805. 
2  Gibson,  op.  cit.,  6th  ed.,  vol.  i.  p.  271. 


FRACTURES    OF    THE    CLAVICLE. 


189 


the  use  of  his  arm  from  the  pressure  upon  the  nerves  by  the  wedo-e- 
shaped  pad,  over  which  the  limb  was  confined,  in  order  to  pry  the 
shoulder  outwards.  Stephen  Smith  mentions  a  case  of  partial  para- 
lysis from  the  same  cause. ^ 

A  similar  case  has  come  under  my  own  observation,  A  lady,  aged 
fifty-one  years,  was  thrown  from  her  carriage,  breaking  the  right 
clavicle  obliquely  at  the  outer  end  of  the  middle  third.  During  the 
first  three  weeks  the  arm  was  dressed  with  Fox's  apparatus,  which 
was  at  no  time  particularly  painful.  She  was  then  placed  under  the 
care  of  another  surgeon,  who,  finding  the  fragments  overlapped,  ap- 
plied very  firmly  a  figure-of-8  bandage,  with  an  axillary  pad,  securing 
the  arm  snugly  to  the  side  of  the  body;  hoping  by  these  means  to 
restore  the  fragments  to  their  place.  The  pain  which  followed  was 
excessive,  and,  notwithstanding  the  free  use  of  anodynes,  it  became  so 
insupportable  that  at  the  end  of  fourteen  hours  the  dressings  were 
removed  by  another  surgeon,  and  Fox's  apparatus  again  substituted. 
These  were  also  applied  much  more  tightly  than  at  first,  and  during 
The  four  weeks  longer  that  they  remained  on,  repeated  attempts  were 
made  to  reduce  the  fragments. 

Forty-eight  days  after  the  accident,  she  consulted  me.  The  clavicle 
was  then  united,  and  overlapped  half  an  inch.  The  whole  arm  was 
swollen,  painful,  and  very  tender,  with  total  inability  to  move  it. 

I  removed  all  the  dressings,  and,  during  the  time  she  remained 
under  my  care,  in  a  private  room  at  the 
hospital,  there  was  a  gradual  improve- 
ment in  the  condition  of  her  arm,  in  re- 
spect to  swelling  and  tenderness,  but  the 
paralysis  did  not  much  abate. 

Erichsen  thinks  he  has  seen  one  case 
of  comminuted  fracture,  produced  by  a 
direct  blow,  in  which  the  subclavian 
artery  was  ruptured ;  great  extravasa- 
tion of  blood  resulted,  and  the  arm  was 
threatened  with  gangrene.  The  patient 
having  recovered,  however,  the  diagno- 
sis could  not  be  determined  by  actual 
dissection.^ 

Since  among  surgeons  some  difference 
of  opinion  seems  to  exist  as  to  the  prac- 
ticability of  overcoming  the  displacement 
in  certain  fractures  of  the  clavicle,  it  is 
proper  that  I  should  defend  the  accuracy 
of  my  own  observations  by  a  reference 
to  the  observations  of  others. 

In  nine  of  eleven  cases  reported  by 
Stephen  Smith,  one  of  the  surgeons  at 
Bellevue  Hospital,  New  York,  more  or  less  deformity  remained  after 


Fi?.  44. 


Velpeau's  dextrine  bandage;  no  axil- 
lary pad. 


'  New  York  Jonrn.  of  Medicine,  May,  1857. 
^  Erichsen,  Surgery,  Amer.  ed.,  p.  205. 


190  FRACTURES    OF    THE    CLAVICLE. 

the  cure  was  completed.  In  the  two  remaining  cases  the  actual  results 
are  unknown.' 

Chelius  remarks :  "  Setting  of  this  fracture  is  easy,  yet  only  in  very 
rare  cases  is  the  cure  possible  without  any  deformity."  *  *  *  * 
"  It  is  considered,  also,  that  the  close  union  of  the  fracture  of  the  collar- 
bone depends  less  on  the  apparatus  than  on  the  position  and  direction 
of  the  fracture  (therefore,  in  spite  of  the  most  careful  application  of 
this  apparatus,  some  deformity  often  remains)."^ 

Velpeau,  in  a  lecture  given  in  18-i6,  and  published  in  the  Gazette 
des  Eointaux,  declares  that  with  all  the  bandages  imaginable,  in  the 
case  of  an  oblique  fracture  at  the  junction  of  the  outer  third  with  the 
inner  two  thirds,  we  cannot  prevent  deformity. 

Vidal  observes:  "Fracture  of  the  clavicle  is  almost  always  followed 
by  deformity,  whatever  may  be  the  perfection  of  the  apparatus  and  the 
care  of  the  surgeon."^ 

"  Hippocrates  has  observed  that  some  degree  of  deformity  almost 
always  accompanies  the  reunion  of  a  fractured  clavicle ;  all  writers 
since  his  time  have  made  the  same  remark  ;  experience  has  confirme(F 
the  truth  of  it,"* 

Turner  remarks  as  follows:  "As  to  the  reduction  of  this  fracture,  it 
must  be  owned  the  same  is  often  easier  replaced  than  retained  in  its 
place  after  it  is  reduced;  for  its  office  being  principally  to  keep  the 
head  of  the  scapula,  or  shoulder,  to  which,  at  one  end,  it  is  articulate, 
from  approaching  too  near,  or  falling  in  upon  the  sternum,  or  breast- 
bone, it  happens  that,  on  every  motion  of  the  arm,  unless  great  care 
be  taken,  the  clavicle  therewith  rising  and  sinking,  the  fractured  parts 
are  apt  to  be  distorted  thereby.  Besides,  even  in  the  common  respira- 
tion, the  costse  and  sternum  aforesaid,  where  the  other  end  of  this  bone 
is  adnected,  together  with  the  motion  of  the  diaphragm,  rising  and 
falling,  especially  if  the  same  be  extraordinary,  as  in  coughing  and 
sneezing,  are  able  to  undo  your  work,  not  to  mention  the  situation 
thereof,  less  capable  of  being  so  well  secured  by  bandage  as  many 
others.  All  which,  duly  considered,  it  is  no  wonder  that  upon  many 
of  these  accidents,  although  great  care  has  been  taken,  these  bones 
are  sometimes  found  to  ride,  and  a  protuberance  is  left  behind,  to  the 
great  regret  particularly  of  the  female  sex,  whose  necks  lie  more  ex- 
posed, and  where  no  small  grace  or  comeliness  is  usually  placed."^ 

Says  Johannis  deGorter:  "Eestituiter  facile  tractis  huraeris  a  min- 
istro  posterius,  dum  simul  suo  genu  locato  ad  spinam  dorsi,  dorsum 
sustentet  minister,  nam  tunc  chirurgus  folis  digitis  claviculam  fractam 
reponere  potest.  Difficilius  autem  in  reposita  seek  retinetur,  sed  loca 
cava  supra  et  infra  claviculam  spleniis  implenda."^ 

Says  Heister,  writing  only  a  little  later:  "The  reduction  of  a  broken 

>  New  York  Journ.  Med.,  May.  1857,  p.  382. 

2  Sj'stem  of  Surgery.  By  J.  M.  Chelius,  of  Heidelberg,  with  notes  by  South. 
First  Amer.  ed.,  vol.  i.  pp.  GOB,  605. 

*  Vidal  (de  Cassis),  Paris  ed.,  vol.  ii.  p.  105. 

•*  Treatise  on  Fractures  and  Luxations.  By  J.  P.  Desault.  Edited  by  Xav. 
Bichat,  and  translated  by  Charles  Caldwell,  M.D.     Philadelphia,  1S05,  p.  S). 

3  The  Art  of  Surgery,  by  Daniel  Turner,  vol.  ii.  p.  256.     London  ed.,  1742. 

s  Johannis  de  Gorter  ;  Cliirurgia  Repurgata,  p.  79.     Lugduui  Batavoruui,  1743. 


FRACTUEES    OF    THE    CLAVICLE.  191 

clavicle  is  not  very  hard  to  be  effected,  especially  when  the  fracture  is 
transverse;  nor  is  it  unusual  for  the  humerus,  with  the  fragment  of 
the  clavicle,  to  be  so  far  distorted  as  not  to  be  easily  replaced  with 
the  fingers;  hut  the  difficulty  is  much  greater  to  Jceep  the  hone  in  its 
2)Iace  when  the  fracture  is  once  reduced,  especially  if  the  hone  was  hroJcen 
ohliquelyy^ 

Amesbury,  after  having  exposed  the  inefficacy  of  all  previous  modes 
of  dressing,  and  especially  of  the  figure-of-8  bandage,  Desault's,  Boy- 
er's,  and  an  apparatus  recommended  by  Sir  Astley  Cooper,  proceeds 
to  describe  his  own  apparatus  and  to  affirm  its  excellence.  It  is,  how- 
ever, not  much  unlike  a  multitude  of  others,  and  is  liable  to  the  same 
objections.^ 

M.  Mayor,  of  Lausanne,  thinks  that  up  to  this  day  no  successful 
mode  of  treatment  has  been  devised.  "Here  everything  appears  as 
yet  so  little  determined,  that  each  day  sees  some  new  propositions  and 
different  procedures,"  etc.  He  believes,  however,  that  in  his  simple 
handkerchief  bandage,  with  straps  across  each  shoulder,  the  indica- 
tions are  most  fully  accomplished  and  the  most  successful  results  are 
obtained.  If,  however,  it  were  to  be  treated  without  apparatus,  the 
horizontal  position,  lying  upon  the  back,  would,  in  the  end,  make  the 
most  perfect  unions." 

Says  M.  Malgaigne :  "  The  prognosis,  considering  the  trivial  charac- 
ter of  this  fracture,  is  sufficiently  difficult.  For,  little  as  may  be  the 
displacement,  the  surgeon  ought  not  to  promise  a  reunion  without  de- 
formity; and  certain  successful  results,  proclaimed  from  time  to  time, 
betray,  on  the  part  of  those  who  relate  them,  the  most  extravagant 
exaggerations."'* 

M.  Nelaton  having  spoken  of  the  various  plans  which  have  been 
suggested  to  retain  this  bone  in  pluce,  and  of  their  inefficiency,  comes 
at  last  to  speak  of  the  handkerchief  bandage  of  M.  Mayor,  and  re- 
marks :-r- 

"This  apparel  is  very  simple;  but  neither  will  it  remedy  the  over- 
lapping." *  *  *  *  "  Of  all  the  apparels  which  we  have  passed 
in  review,  there  is,  then,  not  one  which  fills  completely  the  three  in- 
dications usually  present  in  the  fracture  of  a  clavicle.  None  of  them 
oppose  the  displacement;  they  have  no  effect,  with  whatever  care 
they  may  be  applied,  but  to  maintain  immobility  in  the  limb.  We 
think,  then,  that  it  is  useless  to  fatigue  the  patient  with  an  apparatus 
annoying,  and,  perhaps,  even  painful;  a  simple  sling,  secured  upon 
the  sound  shoulder,  will  be  sufficiently  severe.  Nevertheless,  as  this 
does  not  assure  so  complete  immobility  as  the  bandage  of  M.  Mayor, 
it  is  to  this  that  we  think  the  preference  ought  to  be  given  in  all  cases 
of  fractures  of  the  clavicle,  whether  accompanied  with  displacement 
or  not,  whether  they  occupy  the  middle  or  the  external  part  of  the 

'  Heister's  Surgery,  vol.  i.  p.  134.     London  eel.,  1768. 

2  Treatment  of  Fractures,  by  Joseph  Amesbury,  vol.  ii.  p.  527.     London  ed.,  1S31. 

3  Nouveau  Systeme  de  Delineation  Chirurgicale,  par  Mathias  Mayor,  de  Lausanne, 
p.  384,  etc.  (also  Atlas,  plate  3  figure  23).     Paris  ed.,  1838. 

*  Traite  des  Fractures  et  des  Luxations,  par  J.  F.  Malgaigne,  tome  premier,  p. 
473.     Paris  ed.,  1847. 


192  FRACTUEES    OF    THE    CLAVICLE. 

clavicle.  If  the  fracture  presents  no  displacement,  we  sball  obtain  a 
cure  which  will  leave  nothing  to  be  desired.  If  there  is  a  tendency  to 
displacement,  the  consolidation  will  be  effected  with  a  deformity  more 
or  less  marked;  bi*t  since  this  deformity  is  inevitable,  at  least  with 
adults,  whatever  may  be  the  apparel  which  we  employ,  it  is  evident 
that  the  apparatus  which  causes  the  least  constraint  ought  to  have  the 
preference.  We  may  remark,  farther,  that  this  union  with  deformity 
in  no  wise  impairs  the  free  exercise  of  all  the  movements  of  the  mem- 
bers,'" 

"The  venerable  gentleman  who  stands  at  the  head  of  American 
surgery,  and  whose  manipulations  with  the  roller  approach  very 
nearly  to  the  limits  of  perfection,  informed  us,  in  1824,  that  he  had 
never  seen  a  case  of  fractured  clavicle  cured  by  any  apparatus,  with- 
out obvious  deformity,"^ 

I  need  not  say  that  the  "venerable  gentleman"  to  whom  Dr.  Coates 
refers  in  this  passage  was  the  late  Dr.  Physick,  of  Philadelphia, 

Dr,  Gross  says  that,  according  to  his  experience,  "fractures  of  the 
clavicle  are  seldom  cured  without  more  or  less  deformity,  whatever 
pains  may  be  taken  to  accomplish  the  object,"^ 

Treatment. — If  evidence  were  needed  beyond  that  which  has  been 
furnished,  of  the  difficulty  of  bringing  to  a  successful  issue  the  treat- 
ment of  this  fracture,  it  might  be  supplied,  one  would  think,  by  a 
reference  merely  to  the  immense  number  of  contrivances  which  have 
been  at  one  time  and  another  recommended, 

A  catalogue  of  the  names  only  of  the  men  who  have,  upon  this 
single  point,  exercised  their  ingenuity,  would  be  formidable,  nor  would 
it  present  any  mean  array  of  talent  and  of  practical  skill. 

All  these  surgeons,  however,  have  admitted  the  same  indications  of 
treatment,  viz.,  that  in  order  to  a  complete  restoration  of  the  outer 
fragment,  which  alone  is  supposed  to  be  much  displaced,  we  are  to 
carry  the  shoulder  upwards,  outwards,  and  backwards.  But  as  to 
the  means  by  which  these  indications  can  be  most  easily,  if  at  all,  ac- 
complished, the  widest  differences  of  opinion  have  prevailed  ;  and,  in 
the  debate,  it  may  be  seen  that  while,  on  the  one  hand,  no  invention 
has  wanted  for  both  advocates  and  admirers,  on  the  other  hand,  no 
method  has  escaped  its  equivalent  of  censure. 

Hippocrates,  Celsus,  Dupuytren,  Flaubert,  Lizars,  Pelletan,  and 
others,  directed  the  patients  to  lie  upon  their  backs,  with  little  or  no 
apparatus.  S.  Cooper  and  Dorsey  also  recommend  that  the  patients 
should  be  confined  in  this  position  during  most  of  the  treatment ;  and 
from  the  account  given  by  Dr.  Lente,  it  will  be  understood  that  a 
similar  plan  is  generally  adopted  in  the  New  York  City  Hospital. 
"But  this  result  (deformity)  rarely  happens  when  the  patient  has 
strictly  followed  the  directions  of  the  surgeon,  as  to  position  especially, 

'  Elements  de  Patliologie  Chirurgicale,  par  A.  Nelaton,  tome  premier,  p.  720. 
Paris  ed.,  1844. 

2  Reynal  Coates,  Amer.  Med.  Journ.,  vol.  xviii.  p.  62,  old  series.  It  is  probable 
that  Dr.  Physick  here  referred  to  complete  and  oblique  fractures  of  the  middle 
third,  or  that  Dr.  Coates  has  forgotten  the  precise  language  employed  on  this  occa- 
sion. 

*  Gross,  System  of  Surgery,  vol.  ii.  p.  155,  1859. 


FRACTURES    OF    THE    CLAVICLE, 


193 


for  it  is  by  position,  more  than  by  any  other  remedial  means,  that  a 
good  result  is  to  be  effected. 

Nearly  the  same  method  we  find  recommended  by  Alfred  Post,  in 
1840,  then  one  of  the  surgeons  of  that  hospital ;  the  arm  being  merely 
kept  in  a  sling  and  boiund  to  the  side,  with  the  patient  lying  upon  his 
back.  Dr.  Post  mentions  a  case  treated  in  this  manner,  which  termi- 
nated with  very  little  deformity  ;^  and  I  have  myself  treated  many 
cases  by  this  plan,  with  more  than  average  success. 

Recently,  Dr.  Edward  Hartshorne,  of  Philadelphia,  has  published, 
in  the  second  volume  of  the  Pennsylvania  Hospital  Reports,  1869,  a 
very  ingenious  argument  in  favor  of  the  supine  position,  in  which  he 
seems  to  have  demonstrated  that  the  special  efficacy  of  this  plan 
depends  upon  the  pressure  made  upon  the  angle  of  the  scapula.  In 
order  to  accomplish  this,  and  to  place  the  scapula  in  the  position  most 
favorable  for  the  reduction  of  the  clavicle,  the  back  should  rest  upon 
a  broad,  firm,  and  unyielding  mattress,  and  not  upon  a  pillow  between 
the  shoulders,  which  latter  has  the  effect  rather  to  defeat  than  to  pro- 
mote the  indication  ;  the  head  should  be  slightly  raised  so  as  to  relax 
the  sterno-cleido-mastoid  muscles  and  somewhat  extend  the  trapezius; 
the  arm  and  forearm  of  the  injured  side  should  be  flexed,  resting  across 
the  chest,  with  the  hand  reaching  over  the  sound  shoulder,  as  recom- 
mended by  Velpeau  in  the  use  of  his  dextrine  apparatus,  or  it  should 
be  placed  at  right  angles  with  the  body,  as  recommended  by  Dupuytren. 

It  is  scarcely  necessary  to  say  that  the  absolute  immobility  required 
by  the  posture  treatment  must  always  limit  its  application,  and  render 
its  general  employment  impossible.  Dr.  J.  A.  Packard,  of  Phila- 
delphia, regards  the  scapula,  also,  as  the  bone  upon  which  the  resto- 
ration of  the  clavicle  chiefly  depends; 
and  he  finds  in  the  serratus  magnus  Fig.  45. 

the  especial  obstacle  to  this  restora- 
tion.^ 

Dr.  Eve,  of  Nashville,  Tenn.,  and  Dr. 
Eastman,  of  Broome  County,  N.  Y., 
have  also  employed  this  method  suc- 
cessfully f  while  Malgaigne  declares  it 
to  be  the  most  reliable  means  of  obtain- 
ing an  exact  union. 

Albucasis,  Lanfranc,  Guy  de  Chau- 
liac.  Petit,  Parr,  Syme,  Skey,  Brun- 
ninghausen,  Parker,  and  very  many 
others,  especially  among  the  English, 
have  preferred,  in  order  to  carry  the 
shoulders  back,  a  figure-of-8 ;  while 
Desault,  Colles,  South,  and  Samuel 
Cooper  have  represented  this  bandage  Fignre-of-s. 

as  useless,  annoying,  and  mischievous. 

'  N.  Y.  Journ.  of  Med.,  vol.  ii.  p.  226. 

2  Packard,  New  York  Journ.  of  Med.,  18fi7. 

3  Bost.  Med.  and  Surg.  Journ.,  vol.  Ivi.  p.  4G8. 


19-i  FRACTUEES    OF    THE    CLAVICLE. 

Heister,  Chelius,  Miller,  Breffield,  Keckerly,^  Coleman,'^  Hunton,^ 
prefer,  for  this  purpose,  some  form  of  back-splint,  extending  from 
acromion  to  acromion,  against  which  the  shoulders  may  be  properly 
secured.  Parker  says  that  splints  of  this  kind,  with  a  figure-of-8 
bandage,  are  "  better  than  all  the  apparatus  ever  invented,"  while  Mr. 
South  gives  his  testimony  in  relation  to  all  dressings  of  this  sort  as 
follows :  "  I  do  not  like  any  of  the  apparatus  in  which  the  shoulders 
are  drawn  back  by  bandages,  as  these  invariably  annoy  the  patient, 
often  cause  excoriation,  and  are  never  kept  long  in  place,  the  person 
continually  wriggling  them  off  to  relieve  himself  of  the  pressure." 

Fox,"  Brown,^  Desault,  and  others  bring  the  elbow  a  little  forwards, 
and  then  lift  the  shoulder  upwards  and  backwards.  Wattman  and 
Lonsdale  carry  the  elbow  still  farther  forwards,  so  as  to  lay  the  hand 
across  the  opposite  shoulder;  while  Guillou  carries  the  hand  and  fore- 
arm behind  the  patient,  and  then  proceeds  to  lift  the  shoulder  to  its 
place. 

Thus  Desault,  Fox,  and  Wattman  accomplish  the  indication  to  carry 
the  shoulder  back,  by  lifting  the  humerus  while  the  elbow  is  in  front 
of  the  body,  and  Guillou  accomplishes  the  same  indication  by  lifting 
the  humerus  when  the  elbow  is  a  little  behind  the  body.  Chelius  also 
says :  "  The  elbow,  as  far  as  possible,  is  to  be  laid  backwards  on  the 
body." 

Sargent,  who  believes  that  with  Fox's  apparatus  "  the  occurrence  of 
deformity  is  the  exception,"  and  not  the  rule,  and  prefers  it  to  all 
others,  has  treated  three  cases  by  Guillou's  method,  and  is  perfectly 
satisfied  with  its  operation.  Hollingsworth,  of-  Philadelphia,  has  also 
treated  one  case  successfully  by  Guillou's  method,  and  adds  his  testi- 
mony in  its  favor. 

But  how  shall  we  explain  these  equal  results  from  opposite  modes 
of  treatment  ?  Is  the  indication  to  carry  the  shoulders  back,  which 
Fox  sought  to  accomplish  by  pressing  the  elbow  upwards  and  back- 
wards, as  easily  attained  by  pressing  the  elbow  upwards  and  forwards? 
Or  are  we  not  compelled  to  infer  that  there  has  been  some  mistake  as 
to  the  precise  amount  of  good  accomplished  by  the  apparatus  in 
either  case  ?  Moreover,  Coates,''  Keal,  and  others  instruct  us  that  the 
only  safe  and  proper  position  for  the  humerus  is  in  a  line  with  the 
side  of  the  body,  and  that  it  must  neither  be  carried  forwards  nor 
backwards. 

Paulus  ^gineta,  Boyer,  Desault,  Pecceti,  Liston,  Fergusson,  Samuel 
Cooper,  Erichsen,    Miller,  Skey,   Levis,    Dorsey,^   Gibson,^  Fox,   H. 

'  Keckerly,  Amer.  Journ.  Med.  Sci.,  vol.  xv.  p.  115;  also,  my  Report  on  De- 
formities after  Fractures,  in  Trans,  of  Amer.  Med.  Assoc,  vol.  viii.  p.  440. 

2  Coleman.  New  York  Journ.  Med.,  second  series,  vol.  iii.  p.  374,  from  New 
Jersey  Med.  Rep. 

3  Hunton,  ibid.;  also,  New  Jersey  Med.  Rep.,  vol.  v.  p.  146. 
*  Fox,  Liston's  Practical  Surgery,  Amer.  ed.,  p.  47. 

5  Brown,  Sargent's  Minor  Surgery,  p.  132. 

6  Coates,  Amer.  Journ.  Med.  Sci.,  vol.  xviii.  p.  62. 

7  Dorsey,  Elements  of  Surgery,  vol.  i.  p.  133. 

6  Gibson,  Institutes  and  Practice  of  Surgery,  vol.  i.  p.  271. 


FRACTURES    OF    THE    CLAVICLE,  195 

H.  Smith/  ISTorris,^  Sargent,  Eastman,^  recommend  an  axillary  pad ; 
while  Richerand,  Velpeau,  Dupuytren,  Benjamin  Bell,  Syme,  deny  its 
utility,  or  affirm  its  danger.  Dr.  Parker  has  seen  one  patient  in  whom 
paralysis  of  the  arm  resulted  from  the  pressure  upon  the  brachial 
nerves,  in  the  attempt  "  to  pry  the  shoulder  out ;"  and  I  have  myself 
recorded  another. 

Cabot,  of  Boston,  Massachusetts,  has  recommended  a  mould  of  gutta 
percha  laid  over  the  front  and  top  of  the  chest." 

Desault's  plan,  which  took  its  origin,  as  Velpeau  thinks,  in  the 
spica  of  Glaucius,  under  various  modifications,  is  recommended  by 
Delpech,  Cruveilhier,  Lasere,  Flamant,  Samuel  Cooper,  Fergusson, 
Liston,  Cutler,  Physick,  Dorsey,  Coates,  and  Gibson;  while  by  Vel- 
peau, Syme,  Colles,  Chelius,  Samuel  Cooper,  and  Parker  it  is  regarded 
as  inefficient  and  troublesome.  Says  Mr.  Cooper :  "In  this  country, 
many  surgeons  prefer  Desault's  bandages;  but  I  do  not  regard  them 
as  meeting  the  indications,  and  consider  them  worse  than  useless." 

The  dextrine  bandages,  or  ajyparatus  'immobile,  of  Blandin,  Velpeau, 
and  others,  constitute  only  another  form  of  the  bandage  dressing  of 
Desault.  In  this  connection  it  ought  to  be  noticed  that  Velpeau  does 
not  regard  the  employment  of  this  apparatus,  or  of  any  other  demand- 
ing great  restraint,  as  imperative.  In  his  great  work  on  anatomy, 
referring  to  the  fact  that  when  the  bone  is  broken  and  overlapped, 
the  patient  is  still  able,  in  many  cases,  to  move  the  arm  freely,  he 
remarks :  "  Do  not  these  cases  give  support  to  the  opinion  of  those 
who  admit  that  fractures  of  the  clavicle  do  not  actually  require  any 
other  apparatus  than  the  simple  supporting  bandage?"  "  It  is  neces- 
sary to  observe,"  he  adds,  "  that  by  thus  acting  we  do  not  prevent  an 
overlapping,"*  etc. 

More  recently.  Dr.  E.  M.  Moore,  of  Rochester,  in  a  paper  read 
before  the  New  York  State  Medical  Society,  in  1871,  has  called  atten- 
tion to  what  he  terms  the  "  Figure-of-8  from  the  elbow,"  by  which  he 
proposes  to  render  tense  the  clavicular  fibres  of  the  pectoralis  major, 
and  at  the  same  time  draw  the  scapula  backwards  towards  the  spine. 
He  is  thus  able,  he  affirms,  to  overcome  the  action  of  the  sterno-cleido- 
mastoid,  which  lifts  the  sternal  fragment;  and  to  carry  the  acromial 
fragment  outwards  and  upwards. 

These  ends  are  accomplished  by  placing  the  arm  in  the  following 
position.  The  end  of  the  middle  finger  resting  upon  the  ensiform 
cartilage,  while  the  elbow  is  pressed  against  the  side  of  the  body. 
In  order  to  maintain  it  in  this  position,  we  may  employ  a  single 
band,  two  and  a  half  yards  long  by  eight  inches  wide— in  the  ac- 
companying wood-cut  a  shawl  is  substituted — the  centre  of  which, 
cravated,  eight  or  ten  inches  wide,  is  laid  against  the  point  of 
the  elbow  and  folded  around  the  arm ;  the  extremity  which  appears 

•  H.  H.  Smith,  Practice  of  Surgery,  p.  354. 

2  Norris,  Liston's  I'ractical  Surg.,  Amer.  ed.,  p.  46. 

3  Eastman,  Apparatus  for  Fractured  Clavicle,  by  Paul  Eastman,  Aurora,  111.; 
Boston  Med.  and  Surg.  Journ.,  vol.  xxiii.  p.  179. 

*  Cabot,  Bost.  Med.  and  Surg.  Jonrn.,  vol.  lii.  p.  233. 
^  Velpeau,  Anatomy,  Amer.  ed.,  vol.  1.  p.  242. 


196 


FEACTUKES    OF    THE    CLAVICLE, 


Fig.  46.  in  front  is  now  carried  up- 

wards over  the  front  of  the 
corresponding       shoulder, 
obliquel}''  downward  across 
the  back   to  the  opposite 
axilla,    and    through    the 
axilla   to  the   front.     The 
other  extremity  emerging 
behind,  between  the  elbow 
and   the   body,  is   carried 
obliquely   upward    to   the 
sound   shoulder,    and    for- 
ward over  this  shoulder,  to 
be  tied  to  the  opposite  ex- 
tremity of  the  shawl  com- 
ino;  from  the  axilla.     The 
forearm  is  then  flexed  at 
an   acute   angle,   and    sus- 
pended by  a  narrow  sling 
passing  under  the  wrist. 
Dr.  Lewis  A.  Say  re,  of  this  city,  has  for  some  time  employed  an 
apparatus  for  dressing  broken  clavicles,  by  which  he  proposes,  also, 
to  render  tense  the  clavicular  attachments  of  the  pectoralis  major, 
and  thus  secure  more  eflectually  the  depression  of  the  sternal  frag- 
ment,   while    at    the    same    time    the 
shoulder  is  lifted  and  carried  back. 

Two  strips  of  adhesive  plaster  are 
prepared,  each  about  three  and  a  half 
inches  wide,  for  an  adult ;  one  long 
enough  to  encircle,  first  the  arm,  and 
then  the  body  completely;  the  other 
of  sufficient  length  to  reach  from  the 
sound  shoulder,  over  the  point  of  the 
elbow  of  the  broken  limb,  and  across 
the  back  obliquely  to  the  point  of 
starting.  Maw's  moleskin  plaster,  or 
some  plaster  equally  strong,  is  to  be 
preferred. 

The  first  strip  is  looped  around  the 
arm  just  below  the  axillary  margin  and 
pinned,  or  stitched,  with  the  loop  suffi- 
ciently open  to  avoid  strangulation. 
The  arm  is  then  drawn  downward  and 
backward  until  the  clavicular  portion 
of  the  pectoralis  major  is  put  suffi- 
ciently on  the  stretch  to  overcome  the 
sterno-cleido-mastoid,  and  thus  draw  the  sternal  fragment  of  the 
clavicle  down  to  its  place.  The  strip  of  plaster  is  then  carried  com- 
pletely around  the  body,  and  pinned  or  stitched  to  itself  on  the  back. 


Fisr.  47. 


FEACTURES    OF    THE    CLAVICLE, 


197 


The  second  strip  is  then  applied,  commencing  on  the  front  of  the 
shoulder  of  the  sound  side,  thence  it  is  carried  over  the  top  of  the 
shoulder,  diagonally  across  the  back,  under  the  elbow,  diagonally 
across  the  front  of  the  chest  to  the  point  of  starting,  where  it  is 
secured  by  pins  or  thread.  A  longitudinal  slit  is  made  in  the  plaster, 
to  receive  the  point  of  the  elbow. 


Fi/?.  48. 


Fii?.  49. 


Before  laying  the  plaster  across  the  elbow,  an  assistant  must  press 
the  elbow  well  forward  and  inward,  and  it  must  be  held  firmly  in 
this  position  until  the  dressing  is  completed.  It  will  be  now  seen 
that  the  arm  has  been  converted  into  a  lever,  whose  fulcrum  is  the 
loop  of  adhesive  plaster  at  the  lower  margin  of  the  axilla ;  and  upon 
this  it  is  believed  that  in  a  great  measure  the  efficiency  of  the  appa- 
ratus depends.  It  is  scarcely  necessary  to  say  that  if  the  plaster 
becomes  loosened,  it  should  be  promptly  readjusted. 

I  have  seen  a  number  of  broken  clavicles  treated  by  this  method, 
and  I  am  prepared  to  affirm  its  general  efficacy ;  but  I  cannot  say 
that  the  proportion  of  cases  in  which  overlapping  has  resulted  is 
less  than  by  the  method  which  I  have  myself  generally  adopted,  and 
which  will  be  described  hereafter.  Under  both  plans  I  have  seen 
some  very  satisfactory  and  some  very  unsatisfactory  results;  and  if 
for  any  reason  I  found  it  inconvenient  to  adopt  my  own  plan,  I  should 
resort  to  Dr.  Sayre's  in  preference  to  any  other. 

The  sling,  in  some  of  its  forms,  is  employed  by  Richerand,  Hu- 
berthal,  CoUes,  Miller,  Fox,  Stephen  Smith,'  H.  li.  Smith,  Bartlett,- 

'  Stephen  Smith,  New  York  Jouni.  Med.,  vol.  ii.  3d  series,  p.  384  Oh\}\  ISoT). 
'^  Bartlett,  my  "Report  ou  Defer.,"  etc.,  Appendix  ;  also,  Bost.  Med.  uud  Surg. 
Journ.,  vol.  li.  p.  404. 


198 


FRACTUKES    OF    THE    CLAVICLE. 


Fitr.  50. 


Levis,'   Dugas,^  Benjamin  Bell,  Bransby   Cooper,   Earle,  Chapman, 
Keal,  and  by  a  large  majority  of  the  English  surgeons. 

No  apparatus,  perhaps,  has  been  so  generally  employed,  among 
American  surgeons,  as  that  form  of  the  sling  introduced   by  Dr. 

George  Fox  into  the  Pennsylvania  Hos- 
pital in  1828. 

Sargent  says  of  it :  "  Fractures  of  the 
clavicles,  treated  by  this  apparatus,  are 
daily  dismissed  from  the  Pennsylvania 
Hospital,  and  by  surgeons  in  private 
practice,  cured  without  perceptible  de- 
formity." 

Norris,  in  a  note  to  Listonh  Practical 
Surgery,  affirms  that  "the  chief  indica- 
tions in  the  treatment  of  fracture  of  the 
clavicle  are  perfectly  fulfilled  by  the 
use  of  this  apparatus." 

II.  H.  Smith,  in  his  Minor  Surgery, 
declares  that  Fox's  apparatus  accom- 
plishes "perfect  cures"  in  very  many 
cases,  and  that  it  is  "  a  very  rare  thing 
for  a  simple  case  to  go  out  of  the  house 
(Pennsylvania  tlospital)  with  any  other 
deformity  save  that  which  time  cures, 
viz.,  the  deposition  of  the  provisional 
callus,"  He  has  also  repeated  substan- 
tially the  same  opinion  in  his  larger 
work,  entitled  Practice  of  Surgery. 

Such  testimony  in  favor  of  any 
dressing  demands  respectful  attention ; 
and  I  shall  not  be  regarded  as  detract- 
ing from  the  respect  due  to  these  authorities,  when  I  express  my 
belief  that  it  is  in  deference  to  the  distinguished  reputation  of  the 
surgeons  who  have  during  the  last  thirty  years  had  charge  of  the 
services  in  that  hospital,  and  who  have  been  so  loud  in  its  praise, 
that  the  use  of  this  apparatus  has,  with  us.  become  so  general.  I 
believe,  also,  that,  in  some  measure,  this  general  preference  is  due 
fairly  to  the  intrinsic  excellence  of  the  dressing.  But  I  must  be  per- 
mitted to  express  a  doubt  whether  it  has  made  deformities  of  the 
clavicle  "  the  exception,  instead  of  the  rule,"  with  us.  I  have  used 
this  dressing  oftener  than  any  other  form,  and  yet  my  success  has  by 
no  means  been  so  flattering  as  has  been  the  success  of  these  gentle- 
men. I  have  seen  others  employ  it,  also,  and  with  pretty  much  the 
same  result.  Nor  ought  it  to  be  forgotten  that,  in  Great  Britain,  by 
far  the  greater  majority  of  surgeons  employ  an  apparatus  essentially 
the  same.  I  have  seen  it  in  many  of  the  hospitals,  and  Mr.  Bicker- 
steth,  one  of  the  surgeons  of  the  Liverpool  Infirmary,  informed  me, 

'  Levis.  H.  H.  Smith's  Practice  of  Surg.,  p.  365.     Am.  Joiirn.  Med.  Sci.,  April, 
1800.  p.  428. 
2  Dugas,  Report  on  Surgery. 


E.  B-irtlett's  Apparatus. — "For  an 
axillary  pad,  roll  a  strip  of  woollen 
flannel,  four  or  five  inches  wide,  around 
the  axillary  strap,  to  the  size  required. 
The  apparatus  may  he  used  for  either 
side  by  changing  the  attachment  of  the 
sling."     (Bartlett) 


FRACTURES    OF    THE    CLAVICLE, 


199 


in  1844  that  it  had  been  in  use  with 
them  as  long  as  thirty  years.  All  that 
has  justly  been  said  against  the  English 
mode  of  dressing  by  slings,  is  equally 
true  of  this ;  and  whatever  has  been 
affirmed  of  the  danger  of  using  an  axil- 
lary pad  applies  as  much  to  this  as  to 
any  other  mode  of  using  the  same. 

I  believe,  however,  that  in  the  Penn- 
sylvania Hospital  the  axillary  pad  em- 
ployed is  not  so  large,  and  especially 
not  so  thick,  as  that  recommended  by 
Desault,  and  in  this  respect  it  is  plainly 
an  improvement;  but  then,  in  the  same 
proportion  that  it  is  made  less  thick,  it 
is  less  powerful  to  accomplish  the  indi- 
cation in  question;  and  if  it  merely  fills 
the  axillary  space,  then  it  is  no  longer 
a  fulcrum  upon  which  the  arm  is  to 
operate  as  a  lever. 

Eegarding,  then,  the  importance  of 
this  question  to  the  interests  of  surgery, 
and  observing  the  wide  differences  of 
opinion  which  are  entertained  here  and 
elsewhere  as  to  the  real  value  of  this 
dressing,  is  it  asking  too  much  of  these 
gentlemen  that  they  will  present  us 
some  more  precise  statistical  testimony  ? 
It  will  be  observed  that  its  advocates 
have  claimed  for  it  what  is  not  to-day, 
at  least,  claimed  for  any  other  apparatus,  viz.,  that  it  is  capable  of  ful- 
filling "  perfectly"  all  the  indications  of  treatment.  By  which  it  must 
be  intended  to  say,  that,  in  addition  to  both  of  the  other  indications, 
that  also  which  has  always  heretofore  been  found  so  difficult,  if  not 
impossible,  the  carrying  out  of  the  shoulder,  is  in  a  majority  of  cases 
perfectly  accomplished — the  clavicles  are  not  shortened. 

If  it  is  intended,  however,  to  say  that  a  shortening  is  not  generally 
prevented,  but  only  that  no  unseemly  projection  of  the  fractured  ends 
will  be  found  to  result,  I  reply,  that  then  it  does  not  answer  all  the 
indications;  and  I  beg,  further,  to  say  that  my  experience  has  con- 
vinced me  that  the  absence  or  presence  of  such  a  projection,  after 
union,  is  due  much  to  the  circumstances  of  the  fracture,  as  to  whether 
it  is  more  or  less  oblique,  and  still  more  especially  to  the  degree  ot 
roundness  or  emaciation  of  the  patient,  rather  than  to  any  form,  or 
part,  or  condition  of  the  apparatus.  It  will  be  found  more  distinct 
in  oblique  fractures  than  in  transverse,  and  much  more  marked  in  thin 
persons  than  in  plump  or  fat  persons,  and  more  so  in  muscular  than 
in  non-muscular.  In  short,  I  affirm  that  such  a  projection  has  oc- 
curred as  often  under  my  observation,  when  this  dressing  has  been 
used,  as  it  has  when  other  forms  have  been  employed. 


George  Fox's  Apparatus  "consists  of  a 
firmly  stutfed  pnd  of  wedge  shape,  and 
about  half  as  long  as  the  humerus,  hav- 
ing a  band  attached  to  each  extremity  o 
its  upper  or  thickest  margin  ;  a  sling  to 
suspend  the  elbow  and  forearm,  made  of 
strong  muslin,  with  a  cord  attached  to 
the  humeral  extremity,  and  another  to 
each  end  of  the  carpal  portion  ;  and  a 
ring  made  of  muslin  stuffed  with  cotton 
to  encircle  the  sound  shoulder,  and 
serve  as  means  of  acting  upon  and  re- 
ceiving the  sling."     (Sargent.) 


200  FRACTURES    OF    THE    CLAVICLE. 

Finally,  while  I  deprecate  incautious  assumptions  in  regard  to  the 
capabilities  of  any  form  of  dressing  for  broken  collar-bones,  a  dispo- 
sition to  which  is  manifested  by  more  than  one  advocate  of  special 
plans,  I  am  ready  to  bear  my  humble  testimony  in  favor  of  that  one 
of  whose  claims  I  have  taken  the  liberty  to  speak  so  freely,  and  which 
is  usually  known  in  this  country  by  the  name  of  Fox's  apparatus, 
consisting  essentially  of  a  sling,  axillary  pad,  and  bandages  to  secure 
the  arm  to  the  chest,  and  to  which  the  stuffed  collar  is  a  convenient 
accessory,  but  which  admits  of  various  modifications,  answering  the 
same  ends.  Among  the  considerable  variety  of  dressings  which  I 
have  used,  this,  either  with  or  without  such  slight  modifications  as  I 
shall  presently  suggest,  has  seemed  to  me  most  simple  in  its  construc- 
tion, the  most  comlbrtable  to  the  patient,  the  least  liable  to  derange- 
ment (if  I  except  Velpeau's  dextrine  bandage),  and  as  capable  as  any 
other  of  answering  the  several  indications  proposed. 

No  apparatus  is  better  able  to  answer  the  first  indication,  namely, 
"to  carry  the  shoulder  up,"  and  thus  to  bring  the  fragments  into  line. 
If,  as  not  unfrequently  happens,  the  outer  end  of  the  inner  fragment 
is  also  carried  a  little  upwards  and  forwards,  it  may  be,  in  some 
measure,  replaced  by  inclining  the  head  to  the  injured  side,  or  by  a 
carefully  adjusted  compress  and  bandage.  But  it  is  not  probable  that 
any  patient  will  consent  to  remain  a  long  time  in  a  position  so  un- 
natural and  constrained  ;  nor  is  it  very  easy,  as  the  experiment  will 
show,  to  maintain  a  steady  pressure  upon  this  portion  of  the  broken 
clavicle. 

The  second  indication,  "  to  carry  the  shoulder  back,"  is  certainly 
much  more  difficult  of  accomplishment  than  the  first;  and  it  does  not 
seem  to  me  to  be  fully  met  by  the  sling  dressing  ;  but  until  some  mode 
is  devised  less  objectionable  than  any  I  have  yet  employed,  or  than 
any  the  mechanism  of  which  I  have  seen  described,  I  see  no  alterna- 
tive but  to  trust  to  that  action  of  the  muscles  attached  to  the  scapula, 
by  which,  as  Desault  first  explained,  when  the  shoulder  is  lifted  per- 
pendicularly, it  is  also  in  some  degree  carried  backwards,  and  that, 
too,  it  has  occurred  to  me  frequently  to  observe,  just  as  much  as  when 
the  upward  pressure  is  made  with  the  elbow  placed  in  front  of  the 
body. 

It  is  my  belief,  however,  from  the  evidences  now  before  us,  that  the 
third  indication,  "to  carry  the  shoulder  out,"  still  remains  unaccom- 
plished ;  that  it  cannot  be  claimed  for  this,  or  for  any  other  apparatus 
yet  invented,  that,  in  a  certain  class  of  cases  which  I  have  sufficiently 
indicated,  constituting  a  vast  majority  of  the  whole  number,  it  is  able 
to  prevent  a  riding  of  the  fragments.  Nor,  seeing  the  difficulties  in 
the  way,  and  the  amount  of  talent  which  has  been  already  devoted  to 
their  removal,  have  I  much  confidence  that  this  end,  so  desirable,  and 
so  diligently  sought,  will  ever  be  attained.  Yet  it  is  presumptuous, 
perhaps,  to  say  what  the  skill  and  ingenuity  of  a  profession  whose 
labors  never  cease,  may  not  hereafter  accomplish. 

Having  already  expressed  my  preference  for  the  sling,  I  have  only 
to  add  wliat  I  consider  necessary  modifications  in  the  form  of  this 
dressing  recommended  by  Dr.  Fox. 


FRACTURES    OF    THE    CLAVICLE. 


201 


Fif 


Dr.  Coates,  in  the  excellent  paper  already  referred  to/  calls  attention 
to  the  danger  of  making  too  much  pressure  upon  the  brachial  artery 
and  nerves,  when  the  axillary  pad  is  used,  and  the  arm  is,  at  the  same 
time,  carried  forwards  upon  the  body.  In  bringing  the  elbow  for- 
wards so  as  to  lay  the  forearm  across  the  body,  the  humerus  is  made 
to  rotate  inwards,  and  the  brachial  artery  and  nerves  are  brought  into 
more  direct  apposition  with  the  pad.  The  same  objection  must  hold, 
only  in  a  greater  degree,  to  M.  Guillou's  method  of  carrying  the  fore- 
arm across  the  back. 

The  humerus  ought  then  to  be  permitted  to  hang  perpendicularly 
beside  the  body,  and  thus  the  nerves  and  bloodvessels  will  be  removed 
in  a  great  measure,  yet  not  entirely,  from  pressure.  The  pad  (to  be 
employed  only  as  a  part  of  the  retentive  means,  and  not  as  a  fulcrum) 
should  be  no  thicker  than  is  necessary  to 
fill  completely  the  axillary  space  when  the 
elbow  is  made  to  press  snugly  against  the 
side  of  the  body. 

I  find  it  necessary  also  to  secure  the  arm 
to  the  body  by  two  or  three  turns  of  a 
roller,  applied  always  lightly  and  with 
great  .care,  so  that  its  pressure  shall  be  in 
no  degree  painful  or  uncomfortable. 

The  stuffed  roller  is  by  no  means  an 
essential  part  of  the  apparatus,  and  I  fre- 
quently suspend  the  broken  arm  by  a  sling 
passed  in  the  ordinary  manner  about  the 
neck  and  over  the  shoulders. 

In  cases  of  partial  fracture^  accompanied 
with  a  persistent  bend  in  the  line  of  the 
axis  of  the  bone,  it  is  proper  to  make  some 
attempt,  by  moderate  pressure  directly  upon 
the  salient  fragments,  to  restore  them  to 
place  ;  but  I  confess  that  I  have  never  yet 
succeeded  in  accomplishing  anything  in 
this  way.  Nor  is  it  a  matter  of  much  con- 
sequence, I  imagine,  since,  as  I  have  already  explained  when  speaking 
of  partial  fractures  in  general,  the  line  of  the  axis  of  the  bone  will 
eventually,  at  least  in  a  majority  of  cases,  be  completely  restored. 

The  onl}'  treatment  which  seems  then  to  be  indicated,  and  the  only 
treatment  which  I  have  of  late  adopted  in  these  cases,  is  to  place  the 
hand  and  forearm  of  the  child  in  a  sling,  or  I  direct  the  mother  to 
make  fast  the  sleeve  to  the  front  of  the  dress  in  such  a  way  that  the 
child  cannot  use  the  arm  until  the  union  is  consummated.  Even  this 
precaution  I  have  several  times  omitted,  with  no  injury  to  the  patient. 

For  a  more  full  consideration  of  partial  fractures  of  the  clavicle,  I 
beg  to  refer  the  reader  to  the  chapter  on  "Partial  Fractures,"  &c. 


The  Author's  Apparatus. 


14 


•  Amer.  Journ.  Med   Sci.,  vol.  xviii.  p.  62. 
2  See  chapter  on  Incomplete  Fracture. 


202  FEACTURES  OF  THE  SCAPULA. 


CHAPTER  XIX. 

FRACTURES  OF  THE  SCAPULA. 

Fractuees  of  the  scapula  may  be  divided  into  those  which  occur 
through  the  body,  the  neck,  the  acromion,  and  coracoid  processes. 

§  1.  Feactures  of  the  Body  or  the  Scapula. 

Under  this  title  I  propose  to  consider  not  only  fractures  of  the 
"  body,"  properly  speaking,  but  also  fractures  of  the  angles  and  of  the 
spine. 

Causes. — It  is  usually  broken  by  the  fall  of  some  heavy  body  directly 
upon  the  bone,  or  by  some  severe  crushing  accident,  by  the  kick  of  a 
horse,  by  a  fall  upon  the  back — in  short,  by  direct  causes  alone,  and  by 
such  causes  as  operate  with  great  violence. 

Malgaigne  says  that  a  Doctor  Heylen  has  recently  published  a  case 
of  this  fracture  which  he  believes  to  have  been  the  result  of  muscular 
action,  occurring  in  a  man  forty-nine  years  old.  The  case,  however, 
is  not  stated  so  clearly  as  to  relieve  us  entirely  of  a  doubt  as  to  the 
nature  and  cause  of  the  accident. 

I  have  myself  recorded  six  cases  which  have  been  under  my  treat- 
ment ;  and  I  think  I  have  observed  in  the  course  of  my  hospital  prac- 
tice three  or  four  other  examples  of  fractures  of  the  body  or  spine  of 
the  scapula  not  caused  by  firearms.  There  are  two  cabinet  specimens 
of  fracture  of  the  body  of  the  scapula  below  the  spine  in  the  Pennsyl- 
vania Medical  College,  and  two  involving  the  spine.  Dr.  Miitter  had 
in  his  collection  a  fracture  of  the  posterior  angle,  and  Dr.  March  had 
a  specimen  of  fracture  of  the  body.  I  believe  also  that  in  the  collec- 
tion of  the  late  Dr.  Charles  Gibson,  of  Richmond,  there  were  one  or 
two  specimens  of  this  fracture,  I  know  of  no  other  museum  speci- 
mens in  this  country  except  my  own  of  partial  fracture,  described  in 
the  chapter  on  Partial  Fractures. 

Ravaton,  after  a  practice  of  fifty  years,  declared  that  he  had  never 
seen  a  fracture  of  the  scapula  except  as  it  had  been  produced  by  fire- 
arms. Among  2358  fractures  reported  from  Hotel  Dieu  during  a 
period  of  twelve  years,  onh'-  four  examples  of  fracture  of  the  scapula 
are  recorded ;  and  at  Middlesex  Hospital,  Lonsdale  has  noticed,  among 
1901  fractures,  only  eight  of  the  body  of  the  scapula. 

The  infrequency  of  this  fracture  is  no  doubt  due  in  a  great  measure 
to  the  elasticity  of  the  ribs,  to  the  mobility  of  the  scapula,  and  to  the 
softness  of  the  muscular  cushion  upon  which  it  reposes. 

Symptoms. — Since  this  bone  is  seldom  broken  except  by  great 
force  directly  applied,  the  usual  signs  of  fractures  are  likely  to  be  con- 


FRACTUEES  OF  THE  BODY  OF  THE  SCAPULA. 


203 


cealed  by  the  speedy  occurrence  of  swelling.  It  is  for  this  reason  that 
it  becomes  necessary,  generally,  that  the  examination  should  be  made 
with  great  care  before  we  can  safely  determine  upon  the  diagnosis.  I 
have  more  than  once  had  occasion  to  correct  the  diagnosis  of  other  prac- 
titioners, who  believed  they  had  discovered  a  fracture  of  the  scapula. 

When,  however,  the  line  of  the  fracture  has  traversed  the  spine, 
and  any  considerable  displacement  has  occurred,  one  ought  to  recog- 
nize the  fracture  easily  by 

merely  carrying  the  finger  Fig-  53. 

along  the  crest. 

If  the  fracture  has  oc- 
curred through  the  body, 
below  or  above  the  spine, 
or  through  either  of  the 
angles,  the  displacement 
may  not  be  so  easily  recog- 
nized. The  surgeon  ought 
then  to  trace  carefully  with 
his  finger  the  outlines  of  the 
scapula,  and  this  he  will  be 
able  to  do  more  satisfactorily 
if  he  places  the  scapula  in 
such  positions  as  elevate  its 
margins  and  render  them 
more  prominent.  In  ex- 
amining the  posterior  angle, 
the  hand  of  the  injured  limb 
may  be  placed  upon  the  op- 
posite shoulder,  the  forearm 
being  carried  across  the  front 
of  the  chest ;  but  in  search- 
ing for  a  fracture  below  the 
spine,  the  forearm  ought  to 
be  laid  across  the  back. 

Crepitus,  which  is  not 
always  present,  owing  to  the  fact  that  the  fragments  overlap  com- 
pletely, or  because  they  have  been  widely  separated  by  the  action 
of  the  muscles,  may  generally  be  detected  by  placing  the  palm  of  the 
hand  upon  some  portion  of  the  scapula,  so  as  to  steady  the  fragment 
upon  which  it  rests,  while  the  arm  is  moved  backwards  and  forwards, 
and  in  various  other  directions,  until  their  broken  surfaces  are  brought 
into  contact. 

Some  degree  of  embarrassment  in  the  motions  of  the  shoulder  and 
arm  must  always  result  from  this  fracture;  sometimes  this  embarrass- 
ment is  very  great,  but  it  ought  not  to  be  considered  ever  as  diagnostie 
of  a  fracture,  since  it  may  be  produced  equally  by  a  severe  contusion  ; 
and  even  when  it  is  accompanied  with  a  fracture,  it  is  due  rather  to 
the  contusion  than  to  the  fracture. 

Pathology,  Seat,  Direction,  &c. — Of  incomplete  fractures  of  the  sca- 
pula, I  have  already  mentioned  that  I  have  seen  one  example. 


Fracture  of  the  posterior  angle  of  scapula,  with  fissure. 
Mutter's  collection,  specimen  C.  No.  187. 


204 


FRACTUEES    OF    THE    SCAPULA, 


Fie.  54. 


Malgaigne  thinks  that  he  has  seen  one  case  of  incomplete  fracture, 
which  occurred  in  a  man  who  was  injured  by  the  fall  of  a  heavy  block 
of  stone,  upon  his  back ;  but  as  the  patient  recovered,  his  diagnosis 
must  remain  doubtful.     I  know  of  no  other  recorded  examples. 

Complete  fractures  occur  most  often  below  the  spine,  and  they  are 
generally  oblique  or  transverse,  sometimes  nearly  longitudinal. 

Fractures  involving  the  spine  are  noticed  occasionally,  but  I  am 
not  aware  that  any  one  has  ever  seen  a  specimen  of  a  fracture  of  the 

spine  alone,  although  many  surgeons  have 
spoken  of  them. 

I  have  mentioned  one  example  of  a  frac- 
ture of  the  posterior  angle  as  being  in  the 
cabinet  of  Dr.  Miitter,  of  Philadelphia. 
Malgaigne  seems  to  doubt  its  existence, 
but  speaks  of  it  as  a  fracture  which  sur- 
geons have  "  imagined." 

Occasionally  the  bone  is  broken  into 
more  than  two  fragments. 

As  a  result  of  the  fracture  there  is  usually 
more  or  less  displacement;  generally,  if 
the  fracture  is  below  the  spine  and  trans- 
verse, and  especially  if  its  direction  is  ob- 
lique from  before  backwards  and  down- 
wards, the  inferior  fragment  is  displaced 
forwards,  or  forwards  and  upwards,  by  the 
action  of  the  serratus  major  anticus,  or  of 
the  teres  major,  while  the  superior  frag- 
ment is  inclined  to  fall  backwards,  and  sometimes  it  is  carried  upwards 
and  backwards,  following  the  action  of  the  rhomboideus  major. 

In  cases  of  comminuted  fracture,  and  occasionally  in  simple  frac- 
tures, the  direction  of  the  displacement  is  reversed,  or  altogether 
changed,  so  that  the  lower  fragment,  instead  of  being  in  front,  is  behind 
the  upper  fragment ;  and  instead  of  overlapping,  the  two  fragments 
are  more  or  less  drawn  asunder.  These  are  deviations  which  are  not 
easily  explained,  but  which  depend,  perhaps,  rather  upon  the  direction 
of  the  blow  than  upon  the  action  of  the  muscles. 

In  a  few  cases  there  is  no  displacement  in  any  direction,  although 
the  crepitus  with  mobility  sufficiently  demonstrates  the  existence  of  a 
fracture. 

Prognosis. — If  displacement  actually  has  taken  place,  it  will  be  found 
very  di,fl&cult,  as  we  shall  see  when  we  come  to  consider  the  treatment, 
to  hold  the  fragments  in  apposition  until  a  cure  is  completed ;  so  that 
they  are  pretty  certain  to  unite  with  a  degree  of  overlapping,  or  other 
irregularity. 

Lonsdale,  Lizars,  Chelius,  Ndlaton,  Gibson,  Malgaigne,  and  others 
have  spoken  of  the  difficulty  or  impossibility  generally  of  keeping 
these  fragments  in  place.  Nekton  and  Malgaigne,  indeed,  confess  that 
they  have  never  succeeded  ;  Gibson  declares  that  it  is  scarcely  possible; 
while  Chelius  affirms  that  if  the  fracture  is  near  the  angle,  the  cure  is 
always  effected  with  some  deformity. 


Fractures  of  the  body,  and  acromion 
process  of  the  scapula. 


FRACTURES    OF    THE    BODY    OF    THE    SCAPULA.  205 

But  then  it  is  not  probable  that  the  patient  will  ever  suffer  any 
serious  inconvenience  from  this  irregular  union  of  the  fragments,  since 
the  perfection  of  its  function  depends  less  upon  any  given  form  or  size 
than  in  the  case  of  almost  any  other  large  bone ;  and  if,  as  has  been 
observed  by  Lonsdale,  the  free  use  of  the  arm  is  not  recovered  for  some 
time,  or  if,  as  has  been  noticed  by  B.  Bell,  a  permanent  stiffness  results, 
these  should  be  regarded  as  due  to  the  injury  which  those  muscles 
have  suffered  which  envelop  the  scapula,  or  to  some  injury  of  the 
ligaments  and  muscles  which  surround  the  shoulder-joint. 

In  some  few  examples  upon  record,  the  bone  has  been  so  commi- 
nuted, and  the  soft  parts  adjacent  so  much  injured,  that  suppuration 
and  necrosis  have  ensued.  And  in  one  case  of  gunshot  fracture  of 
the  scapula,  attended  with  much  comminution,  and  resulting  in  ne- 
crosis, I  have  had  occasion  to  remove  the  entire  scapula. 

Treatment. — In  the  treatment  of  this  fracture,  the  first  object  with  all 
surgeons  has  been  to  restore  the  fragments  to  place,  and  this  they  have 
chiefly  sought  to  accomplish  by  position ;  after  which  they  have  en- 
deavored to  immobilize  the  fragments  by  bandages,  &c. 

In  seeking  to  accomplish  the  first  indication,  they  have  placed  the 
shoulder  and  arm  in  a  great  varietj^  of  postures.  Nearly  all  seem  to 
have  regarded  it  as  of  some  importance  that  the  shoulder  should  be 
elevated,  so  as  to  relax  the  muscles  attached  to  the  upper  and  back 
part  of  the  scapula,  and  thus  per.mit  the  ujjper  fragment  to  fall  down- 
wards and  forwards. 

If  we  confine  our  remarks  first  to  fractures  through  the  body,  and 
do  not  include  fractures  of  the  inferior  angle,  this  indication  is  the 
only  one  which  N^laton  and  Mayor  have  sought  to  accomplish,  and 
for  this  purpose  they  employ  a  simple  sling;  while  Amesbury,  Liston, 
Lonsdale,  S.  Cooper,  South,  Skey,  Miller,  Pirrie,  have  added  to  the 
sling  a  bandage  or  roller,  which  is  made  to  inclose  snugly  the  body 
and  arm. 

Erichsen  uses  the  body  bandage  alone,  as  in  fractures  of  the  ribs, 
while  B.  Cooper,  Lizars,  and  Tavernier  employ  a  bandage  which  in- 
closes not  only  the  body,  but  also  the  arm  ;  neither  of  these  last-men- 
tioned surgeons  recommends  a  sling,  or  any  other  means  to  elevate 
the  arm. 

Johannes  de  Gorter  advises  that  a  sling  shall  be  used,  but  that  the 
elbow  shall  be  lifted  away  from  the  side  of  the  body,  so  as  to  relax 
the  deltoid.  Chelius  and  Desault  recommend  the  same  position,  but 
with  the  addition  of  an  axillary  pad,  whose  apex  shall  be  directed 
upwards,  secured  in  place  with  appropriate  bandages. 

Pierre  d'Argelata  used  also  an  axillary  pad,  but  instead  of  a  wedge 
he  recommended  a  simple  roll ;  and  instead  of  lifting  the  elbow  away 
from  the  body,  he  directed  that  the  elbow  should  be  secured  against 
the  side,  making  use  of  the  axillary  roll  as  a  fulcrum. 

Petit  and  Heister  advised  that  the  elbow  and  forearm  should  be  car- 
ried forwards  upon  the  front  of  the  chest,  and  secured  in  this  position. 

In  the  treatment  of  no  other  fracture  perhaps  have  surgeons  differed 
more  widely  as  to  the  indications  than  in  this,  since,  as  we  have  seen, 
some  recommend  the  elbow  to  be  carried  from  the  body,  and  some 


206  FRACTURES  OF  THE  SCAPULA. 

that  it  shall  be  made  to  approach  the  body  ;  one  directs  that  the  elbow- 
shall  fall  perpendicularly  beside  the  chest,  a  second  prefers  that  it  shall 
be  carried  a  little  back,  and  a  third  that  it  shall  be  brought  well  for- 
wards. In  one  thing  alone  have  they  nearly  all  agreed,  namely,  that 
the  elbow  shall  be  lifted  ;  and  generally  also  it  has  been  recommended 
that  the  arm,  forearm,  and  body  shall  be  confined  by  sufficient  band- 
ages to  insure  quietude.  It  might  be  proper  to  conclude,  therefore, 
that  the  sling  and  bandage  constitute  all  of  the  apparatus  which  is 
necessary  or  useful ;  and  that  it  is  relatively  unimportant  whether  the 
elbow  is  near  or  remote  from  the  body,  or  whether  it  is  in  front  of,  or 
behind,  or  beside  the  chest. 

Such,  indeed,  is  the  conclusion  to  which  we  have  ourselves  arrived; 
yet  if,  in  relation  to  the  position  of  the  elbow,  a  choice  were  to  be 
expressed,  we  would  give  the  preference  to  that  in  which  the  arm  is 
laid  vertically  beside  the  body,  or,  perhaps,  with  the  elbow  a  little 
inclined  backwards,  so  as  to  relax  as  completely  as  possible  the  teres 
major. 

It  is  quite  probable,  however,  that  no  single  position  will  be  found 
of  universal  application  ;  and  perhaps  it  would  be  more  safe  to  advise 
the  surgeon  in  any  given  case  first  to  reduce  the  fragments  as  com- 
pletely as  possible  by  manipulation,  and  then  to  place  the  arm  in  such 
a  position  as,  upon  careful  experiment  in  this  particular  instance,  he 
shall  find  enables  him  to  best  retain  them  in  place. 

If,  however,  the  fracture  is  such  as  to  have  separated  the  inferior 
angle  from  the  body,  it  will  be  well  to  follow  the  advice  of  Boyer  and 
of  others,  and  to  place  a  compress  in  front  of  the  inferior  angle,  to 
resist  the  greater  tendency  to  displacement  in  this  direction.  This 
compress  will  more  eftectually  accomplish  this  indication  if  the  roller 
with  which  it  is  secured  to  the  body,  and  with  which  we  seek  to  im- 
mobilize the  scapula  and  chest,  is  turned  from  before  backwards,  or 
in  a  direction  of  antagonism  to  the  action  of  the  muscles  which  pro- 
duce the  displacement. 

Desault,  with  Chelius  and  Bransby  Cooper,  has  recommended  also, 
in  the  case  of  a  fracture  through  the  angle,  that  the  forearm  should 
be  acutely  flexed  upon  the  arm,  and  that  the  hand  should  be  placed  in 
front  of  the  chest,  upon  the  sound  shoulder,  a  position  which  is  always 
irksome,  and  sometimes  insupportable,  and  which  does  not  ofler  in 
any  case  sufficient  advantages  to  render  it  worthy  of  a  trial. 

§  2.  Fractures  of  the  Neck  of  the  Scapula, 

If  by  the  "neck"  of  the  scapula,  surgeons  mean  that  slightly  con- 
stricted portion  of  this  bone  which  is  situated  at  the  base  of  the  glenoid 
cavity — and  it  is  to  this  portion,  we  believe,  that  anatomists  have 
generally  applied  the  term  "  neck" — then  its  fracture  is  certainly  very 
rare.  Indeed,  the  existence  of  this  fracture,  uncomplicated  with  a 
comminuted  fracture  of  the  glenoid  cavity,  is  denied  by  Sir  Astley 
Cooper,  South,  Erichsen,  and  others.  Mr.  South  says  there  is  no  such 
specimen  in  any  of  the  museums  in  London  ;  and  I  have  not  been  able 
to  find  one  in  any  of  the  American  cabinets.     Dr.  Mott  has  said  to  me 


FRACTUEES    OF    THE    NECK    OF    THE    SCAPULA. 


207 


that  he  had  never  seen  a  specimen,  and  that  in  the  natural  condition 
of  the  bone  he  regards  its  occurrence  as  impossible.  Such,  I  confess, 
also  is  ray  own  conviction. 

If,  however,  it  is  intended,  in  speaking  of  fractures  of  the  neck  of 
the  scapula,  to  refer,  as  Sir  Astlej  Cooper  has  done,  only  to  fractures 
extending  through  the  semilunar  notch  behind  the  root  of  the  cora- 
coid  process,  then  its  existence  is  certain ;  yet  the  fracture  is  not  com- 
mon. _  Duverney  has  reported  one  example,  the  existence  of  which  he 
established  by  a  dissection.  The  coracoid  process  was  broken  at  the 
same  time,  but  the  fracture  through  what  was  called  the  neck,  was 
distinct  from  this ;  and  Sir  Astley  has  recorded  three  examples  in 


Fig.  55. 


Fig.  56. 


Comminuted  fracture  of  the  gleaoid 
cavity. 


Fracture  of  the  neck  of  the  scapula ;  according  to 
Sir  Astley  Cooper. 


which  the  diagnosis  was  very  clearly  made  out,  yet  not  actually  proven 
by  an  autopsy. 

Sym'ptoms. — Sir  Astley  justly  remarks  that  "  the  degree  of  deformity 
produced  by  this  accident  depends  upon  the  extent  of  laceration  of  a 
ligament  which  passes  from  the  under  part  of  the  spine  of  the  scapula 
to  the  glenoid  cavity.  If  this  be  torn"  (and  to  this  we  ought  to  add 
the  ligaments  passing  from  the  coracoid  process  to  the  clavicle  and 
acromion  process),  "  the  glenoid  cavity  and  the  head  of  the  os  humeri 
fall  deeply  into  the  axilla,  but  the  displacement  is  much  less  if  this 
remains  whole." 

The  usual  signs  are,  a  depression  under  the  acromion  process,  the 
same  as  in  dislocation  of  the  head  of  the  humerus  downwards,  but  not 
so  deep  ;  the  head  of  the  humerus  felt,  perhaps,  in  the  axilla ;  crepitus, 
and  the  immediate  recurrence  of  the  displacement  whenever,  after  the 
reduction  has  been  fairly  accomplished,  the  arm  is  left  unsupported. 
The  crepitus  is  best  discovered  by  resting  one  hand  upon  the  top  of 
the  shoulder  in  such  a  manner  as  that  a  finger  shall  touch  the  point 
of  the  process,  while  the  arm  is  rotated  and  moved  up  and  down  by 
the  opposite  hand.     It  may  also  be  easily  ascertained  that  the  cora- 


208  FRACTURES    OF    THE    SCAPXTLA. 

coid  process  moves  with  tbe  humerus  instead  of  the  scapula.  Occa- 
sionally, the  accident  is  accompanied  with  paralysis  of  the  arm,  from 
pressure  upon  the  axillary  nerves,  and  a  rupture  of  the  axillary  artery 
is  also  mentioned  by  Dugas.^ 

Treatment. — The  indications  of  treatment  are  three,  namely,  to  carry 
the  head  of  the  humerus,  with  the  glenoid  cavity,  &c.,  up,  to  carry  it 
out,  and  to  confine  the  body  of  the  scapula.  The  first  is  accomplished 
by  a  sling,  the  second  by  a  pad  in  the  axilla,  and  the  third  by  a  broad 
roller  carried  repeatedly  around  the  arm  and  chest  and  across  the 
shoulder. 

§  3.  Fractures  of  the  Acromion  Process. 

Examples  of  fracture  of  the  acromion  process  have  been  reported 
by  Duverney,  Bichat,  Avrard,  A.  Cooper,  Desault,  Sanson,  N^laton, 
Malgaigne,  West,^  Brainard,^  Stephen  Smith,*  and  others.  I  have 
myself  reported  three  examples;^  and  one  more  example  has  come 
under  my  notice  since  the  date  of  that  report. 

In  the  case  seen  by  Cooper  it  entered  the  articulation  of  the  clavicle, 
and  produced  at  the  same  moment  a  dislocation.  Malgaigne  says  it 
occurs  generally  farther  up,  and  posterior  to  the  attachments  of  the 
clavicle,  "near  the  junction  of  the  diaphysis  with  the  epiphysis,"  and 
that  the  fracture  is  in  most  cases  transverse  and  vertical ;  but  Nclaton 
saw  a  case  in  which  the  fracture  was  oblique.  In  the  case  reported 
by  C.  West,  of  Hagerstown,  Md.,  the  fracture  was  through  the  base 
of  the  process.  In  two  of  the  examples  seen  by  me  the  fracture  was 
in  front  of  the  clavicle ;  in  the  third,  occasioned  by  the  fall  of  a  barrel 
of  flour  upon  the  shoulder,  the  fracture  occurred  at  the  acromio-clavi- 
cular  articulation,  and  was  accompanied  with  an  upward  dislocation 
of  the  outer  end  of  the  clavicle ;  and  in  the  fourth  the  fracture  occurred 
at  the  same  point,  but  there  was  neither  displacement  of  the  clavicle 
or  of  the  process,  the  fracture  being  only  recognized  by  the  crepitus 
and  motion. 

There  is  some  reason  to  believe,  I  think,  that  a  true  fracture  of  the 
acromion  process  is  much  more  rare  than  surgeons  have  supposed, 
and  that  in  a  considerable  number  of  the  cases  reported  there  was 
merely  a  separation  of  the  epiphysis ;  the  bony  union  having  never 
been  completed.  If  such  fractures  or  separations  occurred  only  in 
children,  very  little  doubt  might  remain  as  to  the  general  character 
of  the  accident;  but  the  specimens  which  I  have  found  in  the  mu- 
seums, and  the  cases  reported  in  the  books,  have  been  mostly  from 
adults.  It  is  more  difficult,  therefore,  to  suppose  these  to  be  examples 
of  separation  of  epiphyses,  but  I  am  inclined  to  think  that  in  a 
majority  of  instances  such  has  been  the  fact.  It  is  very  probable, 
also,  that  in  the  case  of  many  of  the  specimens  found  in  the  museums, 
called  fractures,  the  histories  of  which  are  unknown,  they  were  united 

'  Remarks  on  Frac.  of  Scapula,  by  L.  A.  Dugas,  Georgia.  Am.  Journ.  Med.  Sci., 
Jan.  1858. 

2  West,  Penin.  Journ.  of  Med.,  vol.  v.  p.  254. 

3  Brainard,  Bost.  Med.  and  Surg.  Journ.,  vol.  xxxi.  p.  501. 
*  S.  Smith.     Hamilton,  Report  on  Deform.,  op.  cit. 


FRACTURES    OF    THE    ACROMION    PROCESS.  209 

originally  by  cartilage,  and  that  in  the  process  of  boiling,  or  of  mace- 
ration, the  disjunction  has  been  completed.  The  narrow  crest  of 
elevated  bone  which  frequently  surrounds  the  process  at  the  point  of 
separation,  and  which  Malgaigne  may  have  mistaken  for  callus,  is 
found  upon  very  many  examples  of  undoubted  epiphyseal  separations 
which  I  have  examined ;  and  this  circumstance,  no  doubt,  has  tended 
to  strengthen  the  suspicion  that  these  were  cases  of  fracture. 

This  opinion  is  confirmed  by  the  remark  of  Mr.  Fergusson,  that  a 
fracture  of  this  process  is  an  accident  "  of  rare  occurrence."  "  I  have 
dissected,"  he  adds,  "a  number  of  examples  of  apparent  fracture  of 
the  end  of  this  process;  but  in  such  instances  it  is  doubtful  if  the 
movable  portion  had  ever  been  fixed  to  the  rest  of  the  bone."  Dr. 
Jackson  says  there  are  four  specimens  in  the  museum  of  the  Massa- 
chusetts Medical  College,  and  in  the  museum  of  the  Boston  Society 
for  Medical  Improvement,  which  might  easily  be  mistaken  for  frac- 
tures;  but  which  only  illustrate  to  how  late  a  period  the  bony  union 
is  sometimes  delayed.  In  one  specimen  the  patient  could  not  have 
been  less  than  forty  years  of  age;  "the  acromial  process  of  each 
scapula  was  fully  formed,  but  having  no  bony  union  whatever  with 
the  bone  itself.     The  union  was  ligamentous,  but  strong  and  close." 

To  the  same  class  belong  several  specimens  in  my  own  collection ; 
specimens  163  and  997  in  Dr.  March's  collection ;  707  in  the  Albany 
College  collection;  two  specimens  in  the  Mutter,  and  one  in  the  Jef- 
ferson Medical  College  museums. 

I  wish  to  mention,  also,  that  in  the  case  of  my  own  specimens  of 
epiphyseal  separation,  as  well  as  most  of  the  specimens  which  I  have 
examined,  the  ends  of  the  fragments  were  closed  with  a  compact  bony 
tissue. 

The  mode  of  development  of  the  scapula  will  explain  these  cases. 
The  scapula  is  formed  from  seven  centres  ;  namely,  one  for  the  body, 
one  for  its  posterior  border,  one  for  its  inferior  border,  two  for  the 
acromion  process,  and  two  for  the  coracoid.  Ossification  of  the  body 
exists  to  a  certain  extent  at  or  near  the  period  of  birth.  It  commences 
in  one  of  the  centres  of  the  coracoid  process,  about  one  year  after 
birth,  and  unites  to  the  body  at  about  the  fifteenth  year.  All  the 
other  centres  remain  cartilaginous  until  from  the  fifteenth  to  the  sev- 
enteenth year,  when  ossification  commences,  and  is  completed  by 
a  common  union  among  all  parts,  usually  between  the  twenty-second 
and  twenty-fifth  years. 

No  doulDt,  however,  a  fracture  of  this  process  does  occasionally  take 
place.  In  addition  to  my  own,  I  have  already  mentioned  several 
other  examples,  some  of  which  have  been  confirmed  by  dissection; 
and  in  the  case  mentioned  by  Stephen  Smith,  an  autopsy,  made  three 
weeks  after  the  accident,  showed  a  fracture  without  displacement,  the 
periosteum  covering  its  upper  surface  not  being  torn ;  the  fragment 
could  be  turned  back  as  upon  a  hinge. 

Prognosis. — The  process  generally  unites  with  a  slight  downward 
displacement.  This  occurred  in  at  least  two  of  the  examples  seen  by 
me ;  but  in  such  cases  the  motions  of  the  arm  are  not  in  consequence 
much,  if  at  all,  embarrassed ;  unless,  indeed,  it  is  so  much  depressed 


210 


FRACTUEES    OF    THE    SCAPULA, 
Fia;.  57. 


Scapula,  with  epiphyses.     (From  Gray.) 

as  to  interfere  with  the  upward  movements  of  the  arm;  a  result  which 
Heister  erroneously  supposed  was  inevitable. 

Sir  Astley  Cooper  says  that  a  true  bony  union  is  rare  in  these  frac- 
tures, and  that  there  generally  results  a  false  joint,  the  fragments  uniting 
by  a  fibrous  tissue;  but  sometimes  the  surfaces,  instead  of  uniting 
either  by  bone  or  ligament,  become  polished,  and  even  eburnated. 

Malgaigne  has  noticed,  also,  in  a  specimen  contained  in  theDupuy- 
tren  museum,  a  hypertrophy  of  the  lower  fragment,  this  portion  having 
a  diameter  nearly  twice  as  great  as  that  of  the  portion  from  which  it 
was  detached. 

Symptoms. — Where  no  displacement  exists,  the  diagnosis  must 
always  be  difficult,  if  not  impossible.  In  such  a  case  we  could  only 
be  instructed  by  the  manner  in  which  the  injury  had  been  received, 
by  the  contusion,  and  by  the  presence  of  mobility  or  crepitus. 

In  examples  attended  with  displacement,  if  no  swelling  is  present, 
the  finger  carried  along  the  spine  of  the  scapula  to  its  extremity,  will 
easily  detect  the  fracture  by  the  abrupt  termination  of  the  process,  or 
by  the  presence  of  a  fissure,  or  a  depression  ;  but  as  to  the  other  symp- 
toms, they  must  depend  very  much  upon  the  point  at  which  the 
fracture  has  taken  place.  If  in  front  of  the  acromioclavicular  articu- 
lation, the  position  of  the  arm  in  its  relations  to  the  body  will  not  be 
changed ;  but  if  the  fracture  is  through  the  articulation,  and  a  dis- 


FEACTURES    OF    THE    CORACOID    PROCESS.  211 

location  of  the  clavicle  results,  or  if  it  is  behind  the  acromio-clavicular 
articulation,  the  arm,  having  in  either  case  lost  the  support  of  the  cla- 
vicle, will  assume  the  same  position  that  it  does  in  a  fracture  of  the  cla- 
vicle; that  is,  the  shoulder  will  fall  downwards,  inwards,  and  forwards. 

Treatment. — If  the  fracture  has  taken  place  in  front  of  the  acromio- 
clavicular articulation,  no  doubt  the  most  rational  plan  of  treatment 
is  that  recommended  by  Delpech  ;  that  is,  placing  the  patient  in  bed, 
upon  his  back,  and  carrying  the  arm  out  from  the  body  nearly  to  a 
right  angle;  since  by  this  method  the  fragment  is  not  only  lifted,  but 
the  deltoid  muscle  is  relaxed,  and,  consequently,  the  fragment  is  no 
longer  forcibly  drawn  away  from  the  spine  of  the  scapula.  If,  there- 
fore, the  patient  will  submit  to  this  treatment  for  a  sufficient  length  of 
time,  the  union  must  be  accomplished  with  the  least  possible  amount 
of  displacement.  In  case  he  will  not  consent  to  such  confinement,  I 
am  confident  no  other  plan  which  has  been  recommended  merits  a 
trial,  unless  it  be  simply  to  place  the  arm  in  a  sling  until  the  union  is 
accomplished. 

If,  however,  the  fracture  has  taken  place  at  or  behind  the  junction 
of  the  clavicle  with  the  process,  the  indications  of  treatment  must  be 
in  all  respects  the  same  as  in  a  fracture  of  the  clavicle. 

§  4.  Fractures  of  the  Coracoid  Process. 

"  The  coracoid  process,"  says  Mr.  Lizars,  "  is  said  to  be  broken  off, 
but  this  I  question  very  much;  it  must  be  along  with  the  glenoid 
cavity,  or  there  must  be  a  fracture  of  the  neck  of  the  scapula," 

Dr.  Neill,  of  Philadelphia,  has  in  his  cabinet  a  specimen  of  separa- 
tion of  this  process  at  about  one  inch  from  its  extremity.  The  line  of 
separation  is  somewhat  irregular ;  there  is  no  callus,  but  it  is  united 
to  the  upper  portion  by  a  dried  tissue,  half  an  inch  in  length,  and  con- 
tinuous with  the  periosteum.  This  has  been  regarded  as  an  example 
of  fracture ;  but  although  the  scapula  is  large,  and  evidently  belongs  to 
an  adult,  the  fact  that  the  acromion  process  is  not  yet  united  by  bone 
renders  it  probable  that  this,  also,  is  an  epiphyseal  separation.  Prof. 
Charles  Gibson,  of  Eichmond,  Va.,  has  informed  me  also  that  he  has  in 
his  cabinet  a  dried  specimen,  from  an  adult,  which  has  been  broken 
obliquely  near  the  end,  but  which  is  now  united  by  a  ligamentous  or 
fibrous  tissue  of  one  line  and  a  half  in  length.  The  fragment  is  dis- 
placed a  little  forwards,  as  well  as  downwards.  Reuben  D.  Mussey, 
of  Cincinnati,  possessed  a  very  remarkable  and  conclusive  example 
of  this  fracture.  The  humerus  is  dislocated  forwards,  the  head  and 
neck  being  firmly  united  to  the  neck  and  venter  of  the  scapula,  while 
at  the  same  time  the  coracoid  process  is  broken  and  displaced.  Dr. 
Jackson,  of  Boston,  says  that  specimen  No.  453  in  the  museum  of  the 
Massachusetts  Medical  College  seems  clearly  to  have  been  a  fracture 
involving  the  base  of  the  coracoid  process,  and  which,  having  taken 
place  sornewhere  within  a  year  of  the  death  of  the  person,  had  become 
united  by  bone,  and  that  just  before  death  the  process  had  broken  off, 
and  so  completely,  as  to  involve  a  portion  of  the  glenoid  cavity.^ 

1  The  author's  Report  on  Deformities,  op.  cit. 


212 


FRACTUEES  OF  THE  SCAPULA. 


Bransby  Cooper  relates  a  case  of  fracture  through  the  base,  which 
after  eight  weeks,  when  the  patient  died,  was  found  to  be  united  by  a 
ligament.  The  acromion  process  was  broken  at  the  same  time,  and 
had  united  in  the  same  manner.  The  head  of  the  humerus  was  also 
broken  and  partly  united.^  One  example  is  said  to  have  occurred  in 
the  practice  of  Dr.  Arnott,  at  the  Middlesex  Hospital,  London,  in 
consequence  of  which  the  patient  died,  when  a  dissection  disclosed 
the  true  nature  of  the  accident.^  Mr.  South  has  also  reported  a  case 
resembling  somewhat  Mussey's,  but  much  more  complicated.  The 
humerus  was  partially  dislocated  forwards,  the  clavicle,  acromion  pro- 
cess, and  the  olecranon  were  broken  as  well  as  the  coracoid  process. 
Neither  the  fracture  of  the  clavicle  nor  of  the  coracoid  process  was 
made  out  until  after  the  patient  died,  which  was  on  the  fourth  day ; 
the  fact  of  the  existence  of  these  fractures  being  then  ascertained  by 
dissection.^  Erichsen  says  there  is  in  the  museum  of  the  University 
College  a  preparation  showing  a  fracture  at  the  base  of  this  process, 
the  line  of  fracture  extending  across  the  glenoid  cavity.*  Duverney, 
Boyer,  and  Malgaigne  have  also  reported  four  additional  examples 
confirmed  by  dissections.* 

The  existence  of  this  form  of  fracture,  established  by  at  least  nine 
or  ten  dissections,  can  no  longer  be  denied;  yet  it  is  usually  accom- 
panied with  serious  complications,  such  as  must  in  most  cases  prove 

fatal.  In  the  only  two  cases,  how- 
ever, in  which  I  have  had  reason  to 
believe  that  I  had  to  deal  with  a  frac- 
ture of  this  kind,  the  symptoms  and 
termination  were  less  grave,  although 
they  were  both  complicated  with  an 

,, — -=Ba«*»'^s^s<^///jiiiMr«'        upward  dislocation  of  the  outer  end 

_^j|"" ''^^^^^j^^Mm^t^  ^^  t,he  clavicle.  A  gentleman  resid- 
ing in  the  country  was  struck  by  a 
board  which  fell  edgewise  upon  his 
shoulder.  The  fracture  of  the  cora- 
coid process  does  not  seem  to  have 
been  recognized  by  his  surgeon.  An 
apparatus  was  applied  to  retain  the 
clavicle'in  its  place,  but  after  three 
months,  when  he  called  upon  me,  it 
still  remained  displaced  as  at  first. 
During  all  of  this  time  the  apparatus  had  been  steadily  kept  on.  On  lay- 
ing off  the  dressing,  I  discovered  that  the  coracoid  process  was  de- 
tached, obeying  constantly  the  movements  of  the  head  of  the  humerus, 
but  being  not  at  all  subject  to  the  movements  of  the  scapula.  Some 
months  later  I  examined  the  arm  again,  and  found  the  parts  in  the 
same  condition  as  before,  but  the  functions  of  the  arm  were  not  im- 
paired.    A  girl  was  admitted  to  Bellevue  Hospital  in  November,  1868, 


Fiff 


:3 


Fracture  of  the  coracoid  process. 


'  B.  Cooper,  edition  of  Sir  Astley  on  Frac.  and  Disloc,  Amer.  ed.,  p.  380. 

2  Arnott,  Fergusson's  Surg.,  p.  213. 

3  South,  Lond.  Med.-Chir.  Eev.,  1840,  vol.  xxxii.,  new  series,  p.  41. 

••  Erichsen,  Surgery,  p.  307.  *  Malgaigne,  op.  cit.,  p.  513. 


FRACTURES    OF    THE    HUMERUS.  213 

having  fallen  upon  her  left  shoulder,  and  having  sustained  a  complete 
luxation  of  the  acromial  end  of  the  clavicle,  upwards  and  outwards. 
Upon  careful  examination,  a  fracture  of  the  coracoid  process  was  also 
diagnosticated,  indicated  by  both  mobility  and  crepitus. 

It  has  been  generally  stated  that  when  this  process  is  broken  off,  it 
will  be  carried  downwards  by  the  united  action  of  the  pectoralis  minor, 
the  short  head  of  the  biceps,  and  the  coraco-brachialis  muscles ;  but 
this  will  depend  upon  whether  the  coraco-clavicular  ligaments  are 
ruptured  also;  a  circumstance  which  is  not  very  likely  to  occar,  at 
least  to  any  great  extent ;  and  in  fact  not  one  of  the  well-attested  ex- 
amples of  this  fracture  has  ever  been  accompanied  with  any  consider- 
able displacement  in  this  direction. 

Treatment. — In  a  case  of  simple  fracture  of  the  process,  unattended 
with  any  other  lesions,  it  has  been  recommended  to  place  the  arm  in 
a  sling,  with  the  elbow  advanced  as  much  as  possible  upon  the  front 
of  the  chest,  as  by  this  position  we  relax  somewhat  all  of  the  three 
muscles  having  attachments  to  this  process,  and  then  to  confine  the 
scapula  by  a  few  turns  of  a  roller.  It  is  not  probable,  however,  that 
by  these  measures  we  should  accomplish  enough  to  justify  their  con- 
tinuance if  they  were  found  to  be  painful,  or  even  exceedingly  irk- 
some. Patients  under  my  observation  have  generally  complained 
very  much  of  the  pain  and  discomfort  attending  this  position  of  ex- 
treme flexion  of  the  arm  and  forearm,  first  employed  by  Velpeau  for 
fractures  of  the  clavicle.  Moreover,  I  do  not  think  the  fragments  are 
generally  displaced ;  and  if  they  were,  and  the  final  union  were  to  be 
accomplished  solely  by  ligament,  I  think  the  usefulness  of  the  arm 
would  not  be  at  all  impaired.  Such,  at  least,  has  been  my  experience 
in  the  two  cases  above  recorded,  and  in  both  of  which  no  bony  union 
occurred. 

In  the  graver  forms  of  the  accident,  where  other  bones  about  the 
shoulder  are  broken  or  dislocated,  which,  as  we  have  seen,  constitute 
the  larger  proportion  of  the  whole  number,  the  treatment  must  gene- 
rally have  little  or  no  regard  to  this  particular  injury. 


CHAPTER   XX. 

FRACTURES  OF  THE  HUMERUS. 

It  is  not  sufl&cient  to  consider  fractures  of  this  bone  as  occurring 
through  the  shaft  and  its  two  extremities,  as  some  systematic  writers 
have  done;  since  upon  this  simple  arrangement  it  is  impossible  to  base 
a  natural  division  of  their  causes,  symptoms,  prognosis,  and  treatment. 

We  shall  find  it  necessary  to  consider — 

1.  Fractures  of  the  head  and  anatomical  neck.  (Intra-capsular; 
non  impacted  and  impacted.) 

2.  Fractures  through  the  tubercles.  (Extra-capsular;  non-impacted 
and  impacted.) 


21-i  FEACTURES    OF    THE    HUMERUS. 

3.  Longitudinal  fractures  of  the  head  and  neck,  or  splitting  off  of 
the  greater  tubercle. 

4.  Fractures  of  the  surgical  neck.  (Including  separations  at  the 
upper  epiphysis.) 

5.  Fractures  through  the  body  of  the  shaft,  or  of  the  shaft  below 
the  surgical  neck  and  above  the  base  of  the  condyles. 

6.  Fractures  at  the  base  of  the  condyles.  (Including  separation  at 
the  lower  epiphysis.) 

7.  Fractures  at  the  base,  complicated  with  fractures  between  the 
condyles,  extending  into  the  joint. 

8.  Fractures  or  separations  of  the  internal  epicondyle. 

9.  Fractures  or  separations  of  the  external  epicondyle. 

10.  Fractures  of  the  internal  condyle. 

11.  Fractures  of  the  external  condyle. 

Of  113  fractures  of  the  humerus  examined  by  me,  25  occurred 
through  the  upper  third,  17  through  the  middle  third,  and  71  through 
the  lower  third.  An  observation  which  is  in  contrast  with  the  state- 
ment made  by  Amesbury,  and  which  has  been  repeated  by  Lizars,  B. 
Cooper,  Fergusson,  Gibson,  and  others,  that  this  bone  is  most  often 
broken  in  its  middle  third. 

Of  the  fractures  belonging  to  the  upper  third,  one  was  a  separation 
at  the  junction  of  the  epiphysis  with  the  shaft,  one  was  probably  a 
fracture  at  or  near  the  anatomical  neck,  with  impaction  and  splitting 
of  the  tubercles,  one  was  a  fracture  of  the  greater  tubercle  alone,  and 
16  were  fractures  of  the  surgical  neck. 

Of  the  fractures  belonging  to  the  lower  third,  15  were  through  the 
internal  condyle  and  epicondyle,  18  through  the  external  condyle,  16 
were  at  the  base  of  the  condyles,  6  through  the  condyles  and  across 
the  base  at  the  same  time.  The  remainder,  16,  being  through  the 
shaft,  but  above  the  base. 

Unfortunately,  surgical  writers  have  not  been  agreed  in  the  use  and 
application  of  the  terms  "  head,"  "  neck,"  "  anatomical  neck,"  and  "sur- 
gical neck"  of  the  humerus ;  and,  as  a  consequence,  their  meaning  is 
often  obscure,  and  their  teachings  are  sometimes  contradictory  and 
absurd.^  It  is  necessary,  therefore,  that  we  should  define  them  more 
precisely. 

The  head  of  the  humerus  is  that  smooth,  elliptical  surface,  covered 
by  cartilage  and  synovial  membrane,  which  articulates  with,  and  is 
received  into,  the  glenoid  cavity  of  the  scapula. 

The  anatomical  neck  is  the  narrow  line  immediately  encircling  the 
head,  and  which  receives  the  insertion  of  the  capsular  ligament. 

The  surgical  neck  is  that  portion  which  commences  at  the  lower 
raaro-in  of  the  tubercles,  or  at  the  point  of  junction  between  the  epi- 
physis and  the  diaphysis,  and  which  terminates  at  the  insertion  of  the 
pectoralis  major  and  latissimus  dorsi. 

The  neck  is  all  of  that  portion  included  between  the  head  and  the 
insertion  of  the  pectoralis  major  and  latissimus  dorsi,  comprising  not 
only  the  anatomical  and  surgical  necks,  but  also  the  tubercles,  which 
occupy  the  triangular  space  between  these  two. 

»  Boston  Med.  and  Surg.  Journ.,  June  24,  1858,  p.  410. 


FRACTURES    OF    HEAD    AND    ANATOMICAL    NECK, 


215 


§  1.  Fractures  of  the  Head  and  Anatomical  Neck. 
Non-impacted  and  Impacted.) 


( In  tra-  Capsular; 


Causes. — The  causes  which  have  been  found  competent  to  produce 
fractures  of  the  head  and  anatomical  neck  are,  the  penetration  of  balls 
or  of  other  missiles  directly  into  the  joint,  producing  thus  a  compound, 
and  generally  comminuted,  fracture  of  the  head ;  and  falls,  or  direct 
blows  upon  the  shoulder,  without  penetration. 

Pathology,  Results,  &c. — When  the  fracture  results  from  the  direct 
penetration  of  some  foreign  body  into  the  joint,  it  is  not  only  a  com- 
pound fracture,  but  the  head  of  the  bone  is  almost  necessarily  broken 
into  fragments.  If  the  patients  recover,  sooner  or  later  the  fragments 
have  generally  to  be  removed. 

Fractures  of  the  anatomical  neck,  produced  by  falls  upon  the 
shoulder,  without  penetration,  are,  however,  usually  neither  compound 
nor  comminuted,  but  they  often  follow,  with  a  remarkable  degree  of 
accuracy,  the  line  of  the  insertion  of  the  capsular  ligament,  being 
always,  according  to  Robert  Smith,  within  the  inferior  or  outer  mar- 
gin of  this  insertion.  He  calls  them,  therefore,  intra-capsular.  It  is 
probable,  however — since,  as  we  shall  presently  see,  bony  union  is  not 
denied  to  this  fracture — that  the  line  of  separation  is  not  always,  or 
generally,  perhaps,  completely  within  the  insertion  of  the  ligament, 
but  that  it  is  in  some  degree  extra-articular,  if  not  extra-capsular.  If 
it  is  entirely  intra-articular,  no  doubt  union  of  the  fragments  can  never 
take  place,  and  generally  suppuration  will  ensue,  demanding,  at  a 
period  not  very  remote,  an  operation  for  their  removal,  the  same  as 
in  compound  fractures. 

Gibson,  however,  thinks  that  the  fragment  occasionally  remains, 
being  gradually  absorbed  and  changed  in  figure.     He  says  that  his 
museum  contains  three  or  four  well-marked  cases  of  this  kind,  in  all 
of  which  the  head  has  lost  its  spherical  form,  and 
is  very  much  diminished,  and  rough  and  flattened 
next  to  the  scapula.^     Other  cabinets  contain  simi- 
lar specimens. 

The  displacements  to  which  the  upper  fragment, 
or  the  head  of  the  bone,  is  subject,  are  remarkable, 
and  some  of  them  do  not  seem  to  be  satisfactorily 
explained.  Frequently,  indeed,  its  position  is  not 
sensibly  disturbed,  but  at  other  times  it  is  found 
impacted,  or  driven  into  the  cancellous  structure 
of  the  inferior  fragment,  in  consequence  of  which 
one  or  both  of  the  tubercles  are  frequently  broken 
off. 

Robert  Smith  relates  the  following  case  as  having 
aftbrded  him  his  first  opportunity  of  ascertaining 
by  post-mortem  examination  the  exact  nature  of 
this  form  of  displacement : — 

"  A  female,  set.  47,  was  admitted  into  the  Rich-  p-acture  of  the  auaio- 
mond  Hospital,  under  the  care  of  the  late  Dr.  Mc-    micai  neck. 


1  Gibson,  Elements  of  Surgery,  vol.  i.  p.  279. 


216  FRACTUKES    OF    THE    HUMERUS. 

Dowell,  for  an  injury  to  the  humerus,  the  result  of  a  fall  upon  the 
shoulder.  Five  years  afterwards,  the  woman  was  again  admitted, 
under  the  care  of  Mr.  Adams,  with  an  extra-capsular  fracture  of  the 
neck  of  the  femur,  one  month  after  the  occurrence  of  which  she  died, 
in  consequence  of  an  attack  of  diarrhoea. 

"  The  shoulder  was  of  course  carefully  examined ;  the  arm  was 
slightly  shortened,  the  contour  of  the  shoulder  was  not  as  full  or 
round  "as  that  of  its  fellow,  and  the  acromion  process  was  more  promi- 
nent than  natural.  Upon  opening  the  capsular  ligament,  the  head  of 
the  humerus  was  found  to  have  been  driven  into  the  cancellated  tissue 
of  the  shaft,  between  the  tuberosities,  so  deeply  as  to  be  below  the 
level  of  the  summit  of  the  greater  tubercle;  this  process  had  been 
split  off,  and  displaced  outward ;  it  formed  an  obtuse  angle  with  the 
outer  surface  of  the  shaft  of  the  bone.'" 

The  description  is  accompanied  with  two  excellent  drawings  of  the 
specimen,  showing  the  distance  to  which  the  superior  fragment  had 
penetrated  the  inferior,  and  showing  also  complete  union  by  bone. 

I  believe,  also,  that  in  the  following  example  there  was  a  fracture 
at  or  near  the  anatomical  neck,  with  impaction,  and  splitting  of  the 
tubercles : — 

January  12, 1858,  a  young  man,  aged  about  sixteen  years,  fell  from 
a  height  in  a  gymnasium,  severely  injuring  his  left  shoulder,  I  saw 
him,  with  Dr.  Boardman,  soon  after  the  accident,  and  found  him  com- 
plaining very  much  of  the  shoulder,  which  was  some  swollen  and 
tender.  He  could  not  tell  us  how  he  fell,  nor  could  we  discover  any 
contusions  by  which  to  determine  the  point  where  the  blow  was  re- 
ceived. All  motions  of  the  shoulder-joint  were  painful ;  and  there 
was  a  remarkable  fulness  in  front  of  the  joint,  feeling  like  the  head  of 
the  bone,  yet  not  such  as  is  usually  present  in  a  forward  luxation. 
To  determine  this  more  positively,  however,  the  limb  was  manipulated 
as  for  the  reduction  of  a  dislocation.  Once  during  the  manipulation 
a  feeble  but  distinct  crepitus  was  detected ;  yet  the  position  of  the 
bone  remained  unchanged.  The  head  was  found  to  be  in  the  socket, 
but  the  precise  nature  of  the  injury  was  not  made  out. 

Fifteen  days  later,  when  the  swelling  had  completely  subsided,  a 
careful  examination  was  again  made  by  Dr.  Boardman  and  myself, 
when  we  arrived  at  the  conclusion  that  it  was  a  fracture  through  the 
bicipital  groove,  and  that  the  lesser  tubercle  was  carried  forward  half 
an  inch  or  more  from  its  fellow,  while  the  head  and  the  greater 
tubercle  occupied  their  natural  positions  opposite  the  socket.  The 
fragment  projecting  in  front  presented  a  sharp  point,  and  could  not  be 
confounded  with  any  swelling  of  the  soft  parts.  There  was  a  distinct 
space  between  the  tubercles,  into  which  the  finger  could  be  laid.  No 
depression  existed  under  the  acromion  process  behind,  but,  on  mea- 
surement, the  head  of  this  humerus  was  found  to  be  half  an  inch  wider 
in  its  antero-posterior  diameter  than  the  opposite. 

That  this  fracture  was  accompanied  with  impaction  was  rendered 

I  South,  Fractures  in  Vicinity  of  Joints,  pp.  191-3. 


FRACTUEES    OF    HEAD    AND    ANATOMICAL    NECK.       217 

certain  by  the  repeated  and  careful  measurements  of  the  length  of  the 
humerus,  which  constantly  showed  a  shortening  of  half  an  inch. 

Under  these  circumstances  union  generally  takes  place;  but  it  is 
usually  accompanied  with  the  formation  of  an  irregular  mass  of  osteo- 
phytes, which  encircle  the  head  like  a  coronet;  presenting  in  this 
respect  again  a  remarkable  resemblance  to  extra-capsular  fractures  of 
the  neck  of  the  femur.  This  ensheathing  callus,  as  it  may  be  called, 
is  an  outgrowth  from  the  inferior  fragment,  and  it  sometimes  incloses 
the  upper  fragment  as  the  case  of  a  watch  incloses  the  crystal,  only  in 
a  manner  much  more  irregular,  thus  retaining  it  steadily  in  its  place, 
although  very  little  direct  union  has  occurred.  The  cancellous  tissue, 
nevertheless,  is  occasionally  found  united  completely  by  a  new  and 
intermediate  bony  tissue,  and  at  other  times  by  a  fibrous  tissue,  or  by 
both  fibrous  and  bony  tissue. 

In  some  cases  a  perfect  false  joint  has  been  formed  between  the 
opposing  surfaces,  while  in  a  few  unfortunate  examples  the  head  not 
only  refuses  to  unite,  but  by  its  presence,  as  we  have  already  remarked, 
produces  inflammation  and  suppuration,  resulting  in  its  final  extrusion 
from  the  joint. 

At  other  times  the  upper  fragment  turns  upon  its  own  axis,  and  is 
found  more  or  less  tilted  or  completely  rotated  in  the  socket ;  so  that 
its  cartilaginous  or  articulating  surface  rests  upon  the  broken  surface 
of  the  lower  fragment,  and  its  own  broken  surface  presents  toward 
the  glenoid  cavity. 

Robert  Smith  has  described  a  specimen  of  this  kind  which  he  re- 
moved from  the  body  of  a  woman,  aged  forty,  who  many  years  pre- 
vious to  her  death  fell  down  a  flight  of  stairs,  and  struck  her  shoulder 
with  great  violence  against  the  edge  of  one  of  the  steps.  Whether 
she  applied  to  a  surgeon  or  not  at  the  time  of  the  accident,  Mr.  Smith 
was  not  able  to  ascertain.  After  death  the  shoulder  looked  somewhat 
as  if  there  was  a  dislocation  of  the  humerus  into  the  axilla,  there  being 
a  marked  depression  under  the  acromion  process,  but  the  shaft  of  the 
humerus  was  drawn  upwards  and  inwards  toward  the  coracoid  pro- 
cess. 

When  the  capsular  ligament  was  opened,  the  head  of  the  bone  was 
found  to  have  been  broken  from  the  shaft  through  the  line  of  the  ana- 
tomical neck,  and  to  have  completely  turned  upon  itself;  and  the 
cartilaginous  surface  was  actually  driven  one  inch  into  the  cancellated 
structure  of  the  shaft,  so  as  to  split  off"  the  lesser  tubercle  with  a  por- 
tion of  the  greater.  Only  one-half  of  the  upper  fragment  was  thus 
impacted,  the  other  half  projecting  beyond  the  margin  of  the  lower 
fragment.  Between  the  cartilaginous  surface  and  the  shaft  no  union 
had  occurred ;  but  there  was  complete  bony  union  between  the  upper 
and  lower  fragments,  beyond  the  limits  of  the  cartilage. 

The  upper  surface  of  the  superior  fragment  rested  in  part  against 
the  inner  half  of  the  glenoid  cavity  and  upon  its  inner  margin,  and  in 
part  it  rested  against  the  neck  of  the  scapula  in  the  direction  of  the 
coracoid  process.^ 

'  R.  Smith,  op.  cit.,  pp.  193-6. 
15 


218 


FRACTURES    OF    THE    HUMERUS. 


1^ 


dmk 


si  ^~i-zt,-^^isr^ 


v; 


Fig.  60.  Fig.  61.  Nelaton  saw  a  similar  specimen  in 

the  possession  of  M.  Dubled,  the  revo- 
lution of  the  upper  fragment  being 
complete ;  but  there  was  no  later  dis- 
placement, and  the  union  had  been 
accomplished  in  a  manner  similar  to 
that  which  is  seen  after  intra-capsu- 
lar,  impacted  fractures,  without  re- 
version.^ 

I  have  also  been  permitted  to  ex- 
amine a  specimen  belonging  to  Dr. 
Charles  A.  Pope,  of  St.  Louis,  Mo., 
which  seems  to  have  been  broken 
not  only  through  the  line  of  the 
anatomical  neck,  but  also  through  the 
surgical  neck.  Both  fragments  are 
united  by  bone,  the  lower  fragment 
being  carried  in  the  direction  of  the 
coracoid  process,  while  the  upper 
fragment  appears  to  be  reversed,  so 
that  its  articular  surface  is  directed 
toward  the  shaft,  and  its  broken  sur- 
face articulates  with  the  glenoid  cavity. 
The  history  of  this  specimen  is  un- 
known. 

It  is  possible,  we  think,  that  these 
extraordinary  changes  of  position  were 
not  the  direct  result  of  the  accident 
which  broke  the  bone,  but  that  they 
had  been  taking  place  gradually  and 
through  a  long  period.  It  is  certainly  quite  as  probable  that  the 
constant  motions  of  the  arm  should  accomplish  these  displacements, 
as  that  they  should  be  produced  by  a  direct  blow;  indeed,  the  former 
supposition  appears  to  us  much  the  most  probable. 

There  is  another  supposition  which,  in  my  opinion,  is  capable  of 
explaining  most  of  the  phenomena  usually  present  in  these  cases, 
and  which,  if  admitted,  renders  the  supposition  of  a  fracture  unne- 
cessary. It  is,  that  these  are  all  of  them  examples  of  softening  of 
the  neck  of  the  bone,  as  a  result  of  chronic  inflammation,  ulceration 
&c. ;  and  that  the  changed  position  of  the  head  is  due  to  pressure 
alone,  being  acted  upon  by  the  muscles  which  surround  the  joint, 
and  which  act  all  the  more  vigorously  because  they  partake  also  of 
the  inflammation  which  has  invaded  the  bone.  This  view  of  these 
specimens,  which  had  already  more  than  once  suggested  itself  to  me, 
was  very  strongly  confirmed  by  its  having  occupied  the  mind  also  of 
Br.  Neill,  of  Philadelphia,  and  who  at  his  own  instance  stated  to  me 
that  he  believed  this  was  their  true  explanation.  We  were,  at  the 
time,  examining  Dr.  Pope's  specimen,  already  alluded  to,  and,  on  com- 


Dr.  Pope's  Specimen. 
Front  view.  Side  view. 


'  Nekton,  Elements  de  Pathol.  Chirur.,  torn.  prem.  p.  307. 


LONGITUDINAL    FRACTURES    OF    HEAD    AND    NECK.      219 

paring  it  with  a  specimen  of  dislocation  and  partial  absorption  of  the 
head  of  the  humerus  contained  in  Dr.  Neill's  museum,  the  points  of 
resemblance  were  so  numerous  and  striking  that  we  felt  compelled  to 
doubt  whether  Dr.  Pope's  specimen,  together  with  those  seen  by  Smith 
and  Nelaton,  did  not  belong  to  the  same  class  with  this  of  Neill's. 

In  a  case  of  fracture  of  the  "  cervix  humeri  within  the  capsular  liga- 
ment," examined  by  Sir  Astley  Cooper,  there  was  also  a  complete 
forward  luxation  of  the  head ;  but  ligamentous  union  had  occurred 
between  the  fragments.^  Many  similar  cases  have  been  reported  by 
other  surgeons. 

§  2.  Fractures  through  the  Tubercles.  (Extra-capsula?-;  Non-impacted 

and  Impacted.) 

Under  this  division  we  intend  to  speak  of  all  fractures  traversing 
the  upper  end  of  the  humerus,  and  involving  the  tubercles,  or  of  all 
those  which  occur  between  the  anatomical  neck  on  the  one  hand,  and 
the  epiphyseal  junction,  or  surgical  neck,  on  the  other  hand,  and  which 
may  be  more  or  less  oblique  as  well  as  transverse.  Fractures  of  the 
greater  or  lesser  tubercles  are  of  course  excepted,  since  they  are  more 
properly  longitudinal  fractures,  and  do  not  completely  traverse  the 
diameter  of  the  bone.  Nor  do  we  intend  to  include  those  fractures 
which  occur  at  the  epiphyseal  junction,  since,  being  below  the  princi- 
pal insertion  of  those  muscles  which  are  attached  to  the  tubercles,  tbey 
present  very  peculiar  and  distinctive  features  which  will  demand  for 
them  a  separate  classification. 

Causes,  Pathology,  and  Results. — Fractures  through  the  tubercles, 
like  fractures  through  the  anatomical  neck,  are  the  results  generally 
of  direct  blows  received  upon  the  shoulder.  They  are  not  usually 
accompanied  with  much  lateral  displacement  at  the  point  of  fracture ; 
a  circumstance  which  finds  a  partial  explanation  in  the  fact  that  the 
line  of  fracture  is  through  the  insertions  of  the  muscles  converging 
upon  the  tubercles,  and  not  entirely  above  or  below  them,  so  that  they 
continue  to  act  nearly  equally  upon  both  fragments ;  but  it  is  also 
sometimes  due  in  a  measure  to  impaction :  the  head  being  forced 
downwards  toward  the  axilla,  and  upon  the  shaft  until  it  is  made  to 
ride  upon  its  inner  or  axillary  wall  like  a  cap ;  the  compact  bony 
tissue  of  the  shaft  penetrating  the  reticular  structure  of  the  head. 
These  fractures  generally  unite  by  bone  ;  yet  more  or  less  impairment 
of  the  motions  of  the  limb  results  from  the  inflammation  which  occurs 
in  and  about  the  joint,  or  from  the  irregular  deposits  of  callus  in  the 
vicinity  of  the  fracture. 

§  3.  Longitudinal  Fractures  of  the  Head  and  Neck  ;  or  Splitting  off 
OF  THE  Greater  Tubercle. 

Causes,  Pathology,  Symptoms,  and  Results. — Mr.  Guthrie  seems  to 
have  been  the  first  to  call  attention  to  this  peculiar  injury  of  the 
shoulder.     In  a  lecture  delivered  in  November,  1833,  he  described 

1  A.  Cooper  on  Dislocations,  &c.,  p.  373. 


220  FEACTURES    OF    THE    HUMEEUS. 

four  cases  which  had  come  under  his  observation,  and  which  he  re- 
garded as  examples  of  separation  of  the  small  tuberosity,  accompanied 
with  more  or  less  of  the  head,  the  fracture  extending  along  a  portion 
of  the  bicipital  groove.^ 

Eobert  Smith,  however,  believes  that  it  was  the  greater  and  not  the 
lesser  tuberosity  which  was  thus  detached  in  the  cases  mentioned  by 
Mr.  Guthrie,  since  the  external  signs  were  so  nearly  like  those  which 
were  present  in  a  woman  seen  by  himself,  and  in  whom  an  autopsy 
enabled  him  to  verify  his  diagnosis.  The  following  is  the  case  as 
related  by  Mr.  Smith  : — 

"  In  July,  1844, 1  was  requested  to  examine  the  body  of  Julia  Darby, 
get.  80,  who  had  died  of  chronic  pulmonary  disease.  Upon  entering 
the  room,  the  appearances  of  the  left  shoulder-joint  at  once  attracted 
my  attention,  and  struck  me  as  being  different  from  those  which  attend 
the  more  common  injuries  of  this  articulation. 

"  The  shoulder  had  lost,  to  a  certain  extent,  its  natural  rounded 
form;  the  acromion  process,  although  unusuall}''  prominent,  did  not 
project  as  much  as  in  cases  of  dislocation  of  the  head  of  the  humerus. 
The  breadth  of  the  articulation  was  greatly  increased,  and,  upon  press- 
ing beneath  the  acromion,  an  osseous  tumor  could  be  distinctly  felt, 
occupying  the  greater  part  of  the  glenoid  cavity ;  it  formed  a  promi- 
nence which  was  perceptible  through  the  soft  parts ;  it  moved  along 
with  the  shaft  of  the  humerus,  but  was  manifestly  not  the  head  of  the 
bone. 

"A  second  and  larger  tumor,  presenting  the  rounded  form  of  the 
head  of  the  humerus,  lay  beneath  the  base  of,  and  internal  to,  the  cora- 
coid  process,  and  between  the  two  the  finger  could  be  sunk  into  a  deep 
sulcus,  placed  immediately  below  the  coracoid  process.  The  elbow 
could  be  brought  into  contact  with  the  side,  and  there  was  no  appre- 
ciable alteration  in  the  length  of  the  arm. 

"  Upon  removing  the  soft  parts,  the  head  of  the  bone  presented  itself, 
lying  partly  beneath  and  partly  internal  to  the  coracoid  process.  The 
greater  tuberosity,  together  with  a  very  small  portion  of  the  outer 
part  of  the  head  of  the  bone,  had  been  completely  separated  from  the 
shaft  of  the  humerus.  This  portion  of  the  bone  occupied  the  glenoid 
cavity,  the  head  of  the  humerus  having  been  drawn  inwards  so  as  to 
project  upon  the  inner  side  of  the  coracoid  process;  it  was  still,  how- 
ever, contained  within  the  capsular  ligament. 

"  The  fracture  traversed  the  upper  part  of  the  bicipital  groove, 
which,  in  consequence  of  the  displacement  which  the  head  of  the  bone 
had  suffered,  was  situated  exactly  below  the  summit  of  the  coracoid 
process.  A  new  and  shallow  socket  had  been  formed  upon  the  costal 
surface  of  the  neck  of  the  scapula,  below  the  root  of  the  coracoid  pro- 
cess, and  the  inner  edge  of  the  glenoid  cavity  corresponded  to  the  pos- 
terior part  of  the  sulcus,  which  separated  the  head  of  the  bone  from 
the  detached  tuberosity.  The  latter  was  united  to  the  shaft  only  by 
ligament. 

"The  capsule  had  not  been  injured,  but  was  thickened  and  en- 

'  Robert  Smith,  p.  181,  from  Lond.  Med.  and  Phys.  Journal. 


FRACTURES    THROUGH    THE    SURGICAL    NECK.  221 

larged,  and  the  bone  had  been  deposited  in  its  tissue.  The  injury  had 
evidently  occurred  many  years  before  the  death  of  the  patient,  but 
the  history  connected  with  it  could  not  be  precisely  ascertained."^ 

Mr.  Smith  relates  one  other  case,  in  the  living  subject,  which  he 
saw  in  connection  with  Mr.  Adams,  at  the  Eichmond  Hospital,  and 
he  adds  that  "numerous"  other  living  examples  have  fallen  under  his 
observation. 

Sir  Astley  Cooper  has  also  published  the  particulars  of  a  case  of 
fracture  of  the  greater  tubercle,  which  was  communicated  to  him  by 
Mr.  Herbert  Mayo.^ 

The  following  I  believe  also  to  have  been  an  example  of  this  rare 
accident : — 

John  Hill,  93t.  78,  fell  upon  the  side-walk,  striking  upon  his  right 
shoulder.  The  physician  to  whom  he  was  sent  thought  the  humerus 
was  dislocated,  and  directed  him  to  the  Buffalo  Hospital  of  the  Sisters 
of  Charity,  but  he  did  not  apply  for  admission  until  eight  days  after, 
Oct.  14,  1857,  when  Dr.  Boardman  and  myself  examined  the  limb 
carefully. 

Although  we  placed  him  under  the  influence  of  chloroform,  the 
diagnosis  was  not  satisfactorily  made  out.  We  inclined,  however,  to 
the  opinion  that  it  was  a  fracture  of  the  greater  tubercle.  The  antero- 
posterior diameter  of  the  upper  end  of  the  bone  was  greatly  increased  ; 
there  was  occasional  distinct  crepitus,  but  the  limb  was  not  shortened. 

Subsequently,  the  examinations  were  repeated  many  times,  and  the 
depression  between  the  fragments  becoming  more  palpable,  the  diag- 
nosis was  at  length  confirmed. 

No  treatment  was  adopted,  except  confinement  in  bed,  and  stimu- 
lating embrocations.  Two  months  after  the  accident  he  still  remained 
an  inmate  of  the  hospital,  his  shoulder  being  quite  stiff,  and  the  pro- 
jection continuing  in  front. 

Mr.  Eobert  Smith  thinks  that  when  the  displacement  is  considerable, 
the  fragments  generally  unite  by  ligament,  rather  than  by  bone. 

§  4.  Fractures  through  the  Surgical  Neck.     {Including  Separations  at 

the  Upper  Epiphysis.) 

I  have  already  defined  the  "  Surgical  Neck"  as  all  of  that  narrow 
portion  commencing  at  the  upper  epiphysis  and  terminating  at  the 
insertion  of  the  pectoralis  major  and  latissimus  dorsi.  It  seems 
proper,  therefore,  that  we  should  include  under  this  division  both 
fractures,  and  separations  occurring  at  the  epiphysis,  especially  since, 
owing  to  their  anatomical  relations,  they  are  subject  to  the  same  dis- 
placements as  fractures  occurring  half  an  inch  or  one  inch  lower  down. 
The  capsular  muscles,  with  the  exception  of  the  teres  minor,  having 
no  more  influence  over  the  lower  fragment  when  a  separation  occurs 
at  the  epiphysis,  than  when  a  separation  occurs  at  any  other  point  of 
the  surgical  neck. 

'  Eobert  Smith,  op.  cit.,  p.  178. 

2  A.  Cooper,  on  Dislocations  and  Fractures  of  the  Joints.  Edited  by  B.  Cooper. 
American  edition,  p.  384. 


222 


FRACTURES    OF    THE    HUMERUS. 


t 


Fig.  63.  A  brief  description  of  the  plan  of  development  of 

the  humerus  will  enable  the  reader  better  to  under- 
stand the  occasional  separation  of  the  epiphysis,  both 
at  the  upper  and  lower  ends  of  the  bone. 

The  humerus  is  originally  formed  from  seven  car- 
tilaginous centres,  namely,  one  for  the  shaft,  one  for 
the  head,  one  for  the  greater  tuberosity,  one  for  each 
epicondyle,  and  two  for  the  lower,  articulating  end 
of  the  bone.  At  birth  the  shaft  is  ossified  in  nearly 
its  whole  length.  Between  the  first  and  fourth  years 
ossification  commences  in  the  several  centres  com- 
posing the  upper  end  of  the  bone,  and  they  coalesce 
by  the  end  of  the  fifth  year,  so  as  to  form  a  single 
epiphysis,  which  finally  unites  with  the  shaft  at 
about  the  twentieth  year.  At  the  lower  end  of  the 
bone,  ossification  commences  in  the  radial  portion  of 
the  articular  surface  at  the  end  of  two  years,  in  the 
trochlear  portion  at  twelve  years,  in  the  internal  epi- 
condyle at  the  fifth  year,  and  in  the  external  epicon- 
dyle at  the  thirteenth  or  fourteenth.  At  the  sixteenth 
or  seventeenth  year  all  the  centres  are  joined  to  each 
other,  and  to  the  shaft,  except  the  inner  epicondyle, 
which  does  not  unite  by  bone  until  about  the  eighteenth 
year.  It  will  be  observed,  therefore,  that  although 
ossification  commences  in  the  upper  epiphysis  first,  it 
is  the  last  to  form  bony  union  with  the  shaft. 

The  following  is  an  account  of  a  case  of  separation 
at  the  upper  epiphysis  which  came  under  my  notice  in  1855 : — 

Mike  Bovin,  ast.  13  months,  fell  sideways  from  his  cradle,  causing 
some  injury  to  his  arm  near  the  shoulder.  He  was  taken  to  an  em- 
piric, who  called  it  a  sprain,  and  applied  liniments.  Three  weeks 
after  the  accident  he  was  brought  to  me,  and  I  found  the  arm  hanging 
beside  the  body,  with  little  or  no  power  on  the  part  of  the  child  to 
move  it.  There  was  a  slight  depression  below  the  acromion  process, 
and  considerable  tenderness  about  the  joint;  but  the  shoulder  was 
not  swollen,  nor  had  it  been  at  any  time.  The  liue  of  the  axis  of 
the  bone,  as  it  hung  by  the  side,  was  directed  a  little  in  front  of  the 
socket. 

On  moving  the  elbow  backwards  and  forwards,  the  upper  end  of 
the  shaft  moved  in  the  opposite  directions  with  great  freedom,  and 
could  be  distinctly  felt  under  the  skin  and  muscles.  This  motion  was 
accompanied  with  a  slight  sound,  or  sensation,  a  sensation  not  like 
the  grating  of  broken  bone,  but  much  less  rough.  There  was  no 
shortening  of  the  limb.  When  the  elbow  was  carried  a  little  forwards 
upon  the  chest,  the  fragments  seemed  to  be  restored  to  complete  coap- 
tation ;  and  of  this  I  judged  by  the  restoration  of  the  line  of  the  axis 
of  the  shaft  to  the  centre  of  the  socket,  and  by  the  complete  disappear- 
ance of  the  depression  under  the  point  of  the  acromion  process. 

I  applied  suitable  dressings  to  retain  the  arm  in  this  position ;  but 
five  months  after  the  injury  was  received  the  fragments  had  not 


Humerus,  with 
epiphyses.  (From 
Gray.) 


FRACTURES    THROUGH    THE    SURGICAL    NECK.  223 

united,  and  the  child  was  still  unable  to  lift  the  arm,  although  the 
forearm  and  hand  retained  their  usual  strength  and  freedom  of  motion. 
The  same  crepitus  could  occasionally  be  felt  in  the  shoulder,  and  the 
same  preternatural  mobility.  The  shoulder  was  at  this  time  neither 
swollen  nor  tender.  I  have  since  this  time  met  with  three  more  ex- 
amples, occurring  in  young  men  who  were  respectively  13,  16,  and 
19  years  of  age,  all  of  which  were  unreduced,  the  patients  having 
been  brought  to  me  as  examples  of  unreduced  dislocations. 

Eobert  Smith  and  Sir  Astley  Cooper  both  speak  of  it  as  a  frequent 
accident  in  early  life,  but  the  recorded  cases  are  very  few.  The  case 
mentioned  by  Mr.  Smith  has  been  given  very  much  at  length,  and,  as 
a  characteristic  example,  deserves  to  be  repeated : — 

"  During  the  early  part  of  last  year,  a  boy,  eight  years  of  age,  was 
admitted  to  the  Eichmond  Hospital,  under  the  care  of  Dr.  McDowell. 
About  a  week  previous  to  his  admission  he  had  fallen  upon  the 
shoulder,  and  at  once  lost  the  power  of  using  his  arm. 

"  It  was  at  first  sight  evident  that  there  did  not  exist  any  luxation 
of  the  head  of  the  humerus,  and  it  was  equally  obvious  that  the  case 
was  not  an  example  of  any  of  the  ordinary  fractures  to  which  the  neck 
of  the  bone  is  liable.  There  was  no  diminution  of  the  natural  rotun- 
dity of  the  shoulder,  nor  any  unusual  prominence  of  the  acromion 
process ;  the  head  of  the  bone  could  be  distinctly  felt  in  the  glenoid 
cavity,  and  it  remained  motionless  when  the  arm  was  rotated ;  there 
was  very  little  separation  of  the  elbow  from  the  side,  but  it  was  di- 
rected slightly  backwards. 

"About  three-quarters  of  an  inch  below  the  coracoid  process  there 
existed  a  remarkable  and  abrupt  projection,  manifestly  formed  by  the 
upper  extremity  of  the  shaft  of  the  humerus,  every  motion  imparted 
to  which  it  followed.  Its  superior  surface,  which  could  be  distinctly 
felt,  was  slightly  convex,  and  its  margin  had  nothing  of  the  sharpness 
which  the  edge  of  a  recently  broken  bone  presents  in  ordinary 
fractures. 

"  When  this  projecting  portion  of  the  bone  was  pushed  outwards,  so 
as  to  bring  it  in  contact  witli  the  under  surface  of  the  head  of  the 
humerus  (previously  fixed  as  far  as  it  was  possible  to  do  so),  a  crepitus 
was  produced  by  rotating  the  shaft  of  the  bone.  It  did  not,  however, 
resemble  the  ordinary  crepitus  of  fracture,  but  it  would  be  extremely 
difficult,  by  any  description,  to  convey  a  clear  idea  of  what  the  differ- 
ence consisted  in. 

"  From  a  careful  consideration  of  the  symptoms  and  appearances 
above  mentioned  (taking  into  account  also  the  age  of  the  patient),  the 
diagnosis  was  formed,  that  the  injury  consisted  in  a  separation  of  the 
superior  epiphysis  of  the  humerus  from  the  shaft  of  the  bone.  Va- 
rious mechanical  contrivances  were  employed  in  this  case,  but  all 
proved  ineffectual  in  maintaining  the  fragments  in  their  proper  rela- 
tive position."^ 

Sir  Astley  Cooper  has  also  briefly  described  one  example. 

'  Robert  Smith,  op.  cit.,  p.  201. 


224 


FRACTURES    OF    THE    HUMERUS. 


Fis:.  63. 


Fracture  of  the  surgical  neck  of  the 
humerus.     (From  Gray.) 


"  Its  age  was  ten  years.    The  symptoms  of  the  injury  were,  inability 
of  moving  the  elbow  from  the  side,  or  of  supporting  the  arm,  unless 

by  the  aid  of  the  other  hand,  without  great 
pain.  The  tension  which  succeeded  filled 
up  the  hollow  which  was  at  first  produced 
by  the  fall  of  the  deltoid  muscle.  When 
the  head  of  the  bone  was  fixed,  the  frac- 
tured extremity  of  the  humerus  could  be 
tilted  under  the  deltoid  muscle,  so  as  to  be 
felt,  and  even  shown,  by  raising  the  arm  at 
the  elbow.  Crepitus  could  be  perceived, 
not  by  rotating  the  arm,  but  by  raising  the 
bone  and  pushing  it  outward.  The  cause 
of  the  fracture  was  a  fall  upon  the  shoulder 
into  a  saw-pit  of  the  depth  of  eight  feet."^ 
It  will  be  necessary,  in  order  to  a  full 
understanding  of  the  various  aspects  of  this 
fracture — a  fracture  of  the  surgical  neck — 
to  relate  several  illustrative  examples. 

Case  1.  Simple  fracture,  nev<^r  displaced ; 
union  without  deformity. — Alex.  Balentine, 
aet.  62  ;  admitted  to  the  Buffalo  Hospital  of 
the  Sisters  of  Charity,  December  19,  1851.  He  had  fallen  upon  the 
side-walk,  striking  upon  his  right  arm.  Dr.  Johnson,  of  Buffalo,  had 
reduced  the  fracture  and  applied  appropriate  dressings.  No  union  of 
the  fragments  had  yet  occurred;  but  as  the  surfaces  were  in  appo- 
sition, it  was  only  after  considerable  manipulation,  and  not  until  we 
bent  the  forearm  upon  the  arm,  and  rotated  the  humerus  by  means  of 
the  forearm,  that  the  crepitus  became  distinct,  and  gave  unequivocal 
evidence  of  the  existence  of  a  fracture,  and  of  its  situation. 

The  treatment,  after  admission,  consisted  in  the  application  of  one 
gutta-percha  splint,  accurately  moulded,  and  extending  from  above  the 
shoulder  to  below  the  elbow,  and  encircling  one-half  the  circumference 
of  the  arm  ;  the  splint  being  secured  with  the  usual  bandages,  &c. 
The  result  is  a  perfect  limb. 

Case  2.  Simple  fracture ;  union  with  displacement  and  deformity. — 
"White,  of  Buffalo,  set.  12,  fell  fourteen  feet,  striking  on  the  front  and 
outside  of  the  left  shoulder.  Dr.  P.,  of  Erie  County,  saw  the  lad  within 
three  hours  (July  19,  1853).  He  was  brought  to  me  on  the  fourth  day 
after  the  accident.  The  upper  part  of  the  arm  was  then  very  much 
swollen.  I  found  the  arm  dressed  as  for  a  fracture  of  the  middle  or 
lower  third  of  the  humerus.  It  was  shortened  one  inch.  The  elbow 
was  inclined  backwards,  and  there  was  a  remarkable  projection  in  front 
of  the  joint,  feeling  like  the  head  of  the  bone.  The  hand  and  arm 
were  powerless.  I  suspected  a  dislocation  of  the  head  of  the  humerus 
forwards  ;  and,  having  administered  chloroform,  I  attempted  its  reduc- 
tion with  my  heel  in  the  axilla.  While  making  extension,  I  felt  a 
sudden  sensation  like  the  slipping  of  the  bone  into  its  socket,  but  on 


A.  Cooper,  op.  cit.,  382. 


FRACTURES    THROUGH    THE    SURGICAL    NECK.  225 

examination  I  found  the  projection  continued  as  before,     I  then  re- 
peated the  effort,  with  precisely  the  same  result. 

I  now  applied  an  arm  sling,  and  directed  leeches  and  cold  evapo- 
rating lotions. 

On  the  25th,  five  days  after  the  accident,  it  was  examined  by  Drs. 
Mixer,  McGregor,  Joseph  Smith,  with  myself  We  still  believed  it 
was  a  dislocation,  and,  having  administered  chloroform,  we  again 
attempted  its  reduction.  The  same  slipping  sensation  was  produced 
as  before,  and  the  deformity  was  repeatedly  made  to  disappear;  but, 
on  suspending  the  extension,  it  as  often  reappeared. 

The  character  of  the  accident  was  now  made  apparent,  and  we  pro- 
ceeded at  once  to  apply  the  splint  and  bandages  suitable  for  a  fracture 
of  the  surgical  neck  of  the  humerus,  namely,  a  gutta-percha  splint, 
extending,  on  the  outside,  from  the  top  of  the  shoulder  to  below  the 
elbow,  with  an  arm  and  body  roller  secured  with  flour  paste. 

On  the  31st,  twelve  days  after  the  accident,  Dr.  Wilcox,  Marine  Sur- 
geon at  Buffalo,  saw  the  arm  with  me.  The  fragments  were  displaced 
the  same  as  when  I  first  saw  it,  and  the  same  as  when  no  apparatus 
was  applied.  We  examined  it  again  carefully,  and  attempted  to  make 
the  fragments  remain  in  place,  but  we  were  unable  to  do  so,  except 
while  holding  them  and  making  extension. 

August  9  (twenty-first  day).  I  removed  all  the  dressings.  Motion 
between  the  fragments  had  ceased,  but  the  projection  and  shortening 
remained  as  before ;  now,  also,  the  irregular  projections  of  the  fractured 
bones  were  more  distinctly  felt.  The  dressings  were  never  reapplied. 
Three  months  later  no  change  had  occurred.  He  could  carry  the 
elbow  forwards  freely,  as  well  as  backwards,  the  motions  of  the  shoul- 
der-joint being  unimpaired. 

Case  3.  Simple  fracture,  with  displacement;  resulting  in  deformity 
and  non-union. — L.  B.,  of  Lockport,  set.  43,  was  thrown  from  his  horse 
in  February,  1854,  striking  upon  his  right  elbow. 

Dr.  Maxwell,  an  experienced  surgeon  of  Lockport,  examined  and 
dressed  the  fracture.  Dr.  Fassett  was  present  and  assisted  at  a  subse- 
quent dressing.  Three  surgeons  who  examined  the  arm  before  Dr. 
M.,  called  it  a  dislocation. 

Twelve  weeks  after  the  accident,  Mr.  B.  called  upon  me.  The  right 
arm  was  shortened  one  inch  ;  the  elbow  hung  off  slightly  from  the 
body  ;  the  upper  end  of  the  lower  fragment  was  distinctly  felt  in  front 
of  the  shoulder-joint,  under  the  clavicle,  feeling  very  much  like  the 
head  of  the  bone.  The  fragments  were  not  united,  but  they  could  be 
seized  easily,  and  made  to  move  separately  and  freely.  He  stated  to 
me  that  he  was  subject  to  rheumatism,  and  especially  in  the  shoulder 
and  arm  of  the  side  injured.  He  wished  to  know  whether  it  could 
not  be  "  re-set." 

Two  years  after,  I  found  the  bone  still  ununited.  He  was,  however, 
able  to  write  with  that  hand,  having  first  lifted  his  arm  with  the  other 
hand  and  laid  it  upon  the  table. 

Case  4.  Simple  fracture,  probably  impacted;  resulting  in  deformity. — 
Wm.  A.,  of  Buffalo,  set.  15,  fell  backwards,  June  4,  1855,  striking  on 
his  back  and  left  shoulder.     Dr.  L.  saw  it  immediately,  and,  regarding 


226  FRACTUEES    OF    THE    HUMERUS. 

it  as  a  dislocation,  attempted  its  reduction.  He  subsequently  repeated 
the  attempt.  I  saw  the  patient  with  Dr.  L.  on  the  tenth  day.  The 
arm  was  shortened  one  inch  and  a  half.  The  fragments  were  displaced 
forwards,  projecting  in  front  of  and  a  little  below  the  joint.  As  in 
Case  3,  it  might  easily  be  mistaken  for  the  head  of  the  bone ;  but  the 
difficulty  of  diagnosis  had  been  very  much  lessened  by  the  subsidence 
of  the  swelling.  There  was  no  motion  between  the  fragments ;  nor 
could  the  deformity,  by  any  manipulation  or  extension,  be  made  to 
disappear.     It  was  probably  impacted. 

March  23,  1856,  nearly  ten  months  after  the  accident,  I  found  the 
fragments  remaining  as  when  I  first  examined  the  limb,  and  the  arm 
shortened  one  inch  and  a  half.  The  elbow  hung  a  very  little  back 
from  the  line  of  the  body.  The  upper  end  of  the  lower  fragment  was 
lifted  to  within  one  inch  of  the  head  of  the  humerus ;  the  upper  frag- 
ment having  its  head  in  the  socket,  with  its  lower  end  downwards  and 
forwards.  The  arm  was,  however,  in  every  respect  as  useful  as  before 
it  was  broken.  It  was  equally  strong,  and  he  could  raise  his  arm  as 
high,  and  move  it  in  every  direction  as  freely,  as  he  could  the  other. 

Causes. — Epiphyseal  separations  belong  almost  exclusively  to  the 
periods  of  youth  and  childhood,  but  true  fractures  at  the  surgical  neck 
occur  most  often  in  adult  life ;  with  the  exception  of  one  girl  and  two 
lads,  aged,  respectively,  eleven,  twelve,  and  fifteen  years,  all  of  the 
examples  of  this  latter  accident  recorded  by  me  occurred  in  adults, 
and  of  twenty-eight  cases  in  which  I  find  the  ages  recorded,  the 
average  age  is  about  forty-three  years;  yet  Sir  A.  Cooper  declares 
these  fractures  to  be  most  common  in  infancy,  while  Malgaigne  has 
never  seen  a  case  in  a  person  under  fifty-three  years. 

Both  epiphyseal  separations  and  fractures  at  this  point  are  occa- 
sioned, in  most  cases,  by  direct  blows  or  falls  upon  the  shoulder.  Of 
twenty-seven  examples  in  which  I  find  the  cause  recorded,  eighteen 
were  from  direct  blows,  eight  from  indirect  blows,  and  one  from  mus- 
cular action,  as  in  throwing  a  ball.  Of  the  eight  resulting  from  indi- 
rect blows,  one  was  from  a  fall  upon  the  hand,  seen  by  Desault,  and 
seven  were  from  falls  upon  the  elbow,  of  which  two  were  seen  by 
Desault,  and  five  by  myself. 

Pathology. — I  have  found  the  fragments  sensibly  displaced  in  ten 
cases  out  of  fifteen  ;  a  proportion  much  greater  than  has  been  observed 
by  Malgaigne,  who  has  only  seen  a  displacement  twice  in  more  than 
twenty  cases.  It  is  certain,  however,  that  complete  or  sensible  dis- 
placement is  less  common  in  this  fracture  than  in  most  other  fractures, 
the  broken  ends  being  retained  in  place,  probably,  by  the  long  tendon 
of  the  biceps. 

As  to  the  direction  of  the  displacement,  I  have  seen  the  upper  end 
of  the  lower  fragment  drawn  forwards  and  upwards  toward  the  cora- 
coid  process  four  times,  in  one  of  which  examples  the  upper  fragment 
plainly  followed  in  the  same  direction.  Sir  Astley  Cooper  declares 
that  with  infants  this  direction  is  constant,  and  in  museum  specimens 
I  have  seen  but  one  exception.  In  the  specimens  of  fracture  of  the 
surgical  neck,  with  also  displacement  of  the  head,  belonging  to  Dr. 
Pope,  this  direction  of  the  fragments  is  plainly  seen,  as  also  in  a  spe- 


FEACTURES    THROUGH    THE    SURGICAL    NECK.  227 

cimen  belonging  to  Dr.  Neill,  of  the  Pennsylvania  Medical  College, 
.where  the  lower  fragment  almost  reaches  the  coracoid  process,  and  in 
a  specimen  contained  in  one  of  the  cabinets  of  the  University  of 
Pennsylvania,  where  the  upper  end  of  the  lower  fragment  has  become 
united  by  bone  to  the  coracoid  process. 

The  only  exception  which  I  have  met  with  is  in  the  possession  of 
Dr.  Neill.  In  this  example  the  two  ends  are  tilted  toward  the  axilla. 
In  the  recorded  examples,  also,  I  find  the  displacement  forwards  men- 
tioned four  times,  and  the  displacement  toward  the  axilla  but  once.  I 
am  compelled,  therefore,  to  doubt  the  accuracy  of  Malgaigne's  obser- 
vations, who  thinks  he  has  seen  the  lower  fragment  most  often  drawn 
toward  the  axilla,  as  well  as  the  observations  of  those  who  think  that 
the  upper  fragment  is  generally  displaced  outwards ;  yet,  no  doubt, 
they  do  sometimes  assume  this  position.  Desault  has  seen  them  both 
thrown  backwards ;  while  Dupuytren,  Paletta,  and  others  have  seen 
them  pushed  outwards ;  and  I  have  in  my  cabinet  the  copy  of  a  speci- 
men in  which  both  fragments  are  drawn  outwards,  but  the  lower  frag- 
ment is  to  the  inner  side  of  the  upper. 

When  the  fracture  occurs  at  or  near  the  epiphysis,  it  is  sometimes 
accompanied  with  impaction,  of  the  same  character  as  we  have  already 
described  when  speaking  of  fractures  through  the  tubercles.  Robert 
Smith  has  given,  in  his  treatise,  an  engraving  intended  to  illustrate 
the  relative  position  of  the  fragments  in  extra-capsular  impacted  frac- 
tures, and  the  line  of  separation  very  nearly  corresponds  to  the  line  of 
junction  of  the  epiphysis  with  the  shaft. 

But  in  a  majority  of  cases  no  impaction  occurs.  Dr.  Charles  A. 
Pope,  of  St.  Louis,  Mo.,  has  two  specimens  of  this  kind,  in  which  no 
union  has  taken  place,  nor  is  there  any  evidence  that  impaction  had 
ever  occurred.  In  one  case  the  line  of  fracture  commences  at  the 
junction  of  the  head  with  the  shaft,  and  extends  thence  irregularly 
across  to  a  point  half  an  inch  below  the  greater  tuberosity.  In  the 
second  specimen  the  fracture  commences  at  the  same  point,  and  ter- 
minates three-quarters  of  an  inch  below  the  greater  tuberosity.  In 
relation  to  these  bones.  Dr.  Pope  remarks :  "  These  are  not  cases  of 
detachment  of  the  epiphyses,  as  the  bones  are  evidently  those  of  adults, 
and  there  is,  at  their  lower  extremities  above  the  condyles,  no  trace  of 
an  epiphyseal  line." 

Results. — Eight  of  the  examples  of  fracture  of  the  surgical  neck 
recorded  by  me  are  known  to  have  resulted  in  perfect  limbs,  and  three 
are  more  or  less  deformed.  In  one  of  these  no  bony  union  has  taken 
place  after  the  lapse  of  two  years  or  more.  It  is  satisfactory,  however, 
to  know  that,  with  the  exception  of  this  last  (Case  3),  all  the  i^atients 
have  recovered  the  free  and  complete  use  of  their  arms. 

Symptoms,  or  Differential  Diagnosis  of  Accidents  about  the  Shoulder- 
joint. — No  place  could  be  more  appropriate  than  this  to  call  attention 
to  the  difficulty  of  diagnosis  in  the  case  of  accidents  about  the  shoul- 
der-joint, a  difficulty  which  surgeons  have  constantly  recognized,  and 
which  has  sometimes  rendered  diagnosis  impossible. 

Let  us  first  study  the  ordinary  signs  of  a  dislocation  at  the  shoulder- 


228  FRACTURES    OF    THE    HUMERUS. 

joint,  regarding  this  as  the  type  with  which  the  other  accidents  are  to 
be  conaparcd. 

a.  Signs  of  a  Dislocation.  ( (7a ?«e,  generally  a  fall  upon  the  elbow  or 
hand,  yet  not  very  unfrequently  a  direct  blow.) 

1.  Preternatural  immobility. 

2.  Absence  of  crepitus. 

3.  When  the  bone  is  brought  to  its  place,  it  will  usually  remain 
without  the  employment  of  force. 

These  three  are  common  signs,  which  apply  to  any  other  joint  as 
well  as  to  the  shoulder. 

4.  Inability  to  place  the  hand  upon  the  opposite  shoulder,  or  to 
have  it  placed  there  by  an  assistant,  while  at  the  same  time  the  elbow 
touches  the  breast.  This  is  a  sign  common  to  all  of  the  dislocations 
of  the  shoulder.' 

The  following  are  special  signs,  or  such  as  belong  only  to  particular 
dislocations  of  the  shoulder. 

5.  Depression  under  the  acromion  process ;  always  greatest  under- 
neath the  outer  extremity,  but  more  or  less  in  front  or  behind,  accord- 
ing as  the  dislocation  may  be  into  the  axilla,  forwards  or  backwards. 

6.  Round,  smooth  head  of  the  bone  sometimes  felt  in  its  new  situa- 
tion, and  very  plainly  removed  from  its  socket ;  moving  with  the  shaft. 
Absence  of  the  head  of  the  bone  from  the  socket. 

7.  Elbow  carried  outwards,  and  in  certain  cases  forwards  or  back- 
wards, and  not  easily  pressed  to  the  side  of  the  body. 

8.  Arm  shortened  in  the  dislocation  forwards,  and  slightly  length- 
ened or  its  length  not  changed,  when  in  the  axilla. 

b.  Signs  of  a  Fracture  of  the  Neck  of  the  Scapula.  {Cause,  generally 
a  direct  blow.) 

1.  Preternatural  mobility. 

2.  Crepitus,  generally  detected  by  placing  the  finger  on  the  coracoid 
]>rocess  ami  the  opjiosite  hand  upon  the  back  of  the  scapula,  while  the 
head  of  the  humerus  is  ))ushcd  outwards  and  rotated. 

3.  When  reduced,  it  will  not  remain  in  place. 

4.  The  hand  may  generally,  but  with  difiiculty,  be  placed  upon  the 
opposite  shoulder,  with  the  elbow  resting  upon  the  front  of  the  chest. 

5.  Depression  under  the  acromion  process,  but  not  so  marked  as  in 
dislocation. 

().  Head  of  the  bone  may  be  felt  in  the  axilla,  but  less  distinctly  than 
in  dislocation.  Never  much  forwards  or  backwards.  Head  of  the  bone 
moves  with  the  shaft.  Head  of  the  bone  not  to  be  felt  under  the  acro- 
mion process,  although  it  has  not  left  its  socket. 

7.  Elbow  carried  a  little  outwards,  but  not  so  much  as  in  dislocation. 
Easily  brought  against  the  side  of  the  body. 

8.  Arm  lengthened. 

9.  The  coracoid  process  carried  a  little  toward  the  sternum,  and 
downwards. 

'  Report  on  a  New  Prineiple  of  Diagnosis  in  Dislocations  of  tlio  Shoulder-joint, 
by  L.  A.  Dugas,  Prof,  of  Sin-gcry  in  the  Medical  College  of  Georgia.  Trans.  Amer. 
]Sted.  Assoc,  vol.  x.  p.  175. 


DIFFERENTIAL    DIAGNOSIS    OF    ACCIDENTS.  229 

10.  Pressing  upon  the  coracoid  process,  it  is  found  to  be  movable, 
and  it  is  also  observed  that  it  obeys  the  motions  of  the  arm. 

c.  Sif/ns  of  Fracture  of  the  Anatomical  Neck  of  the  Humerus.  Intra- 
Capsular.  (Caitse,  a  direct  blow;  generally  opening  to  the  joint,  but 
not  always.) 

1.  Mobility  not  increased,  nor  diminished. 

2.  Crepitus,  generally  discovered  by  pressing  up  the  head  of  the 
bone  into  its  socket  and  rotating;  or,  when  the  tubercles  are  also 
broken,  by  grasping  the  tubercles  and  rotating  the  arm. 

3.  Fragments  not  generally  displaced. 

4.  The  hand  can  be  placed  easily  upon  the  opposite  shoulder,  with 
the  elbow  against  the  front  of  the  chest. 

5.  Very  slight,  if  any,  depression  under  the  acromion  process. 

(j.  Head  of  the  bone  generally  in  its  socket,  but  not  felt  so  distinctly 
as  before  the  fracture. 

7.  Elbow  falls  easily  against  the  side  of  the  body,  or  is  easily  placed 
there. 

8.  Arm  not  lengthened,  nor  appreciably  shortened,  unless  the  head 
be  driven  so  much  into  the  body  as  to  separate  the  tubercles. 

9.  In  this  latter  case  there  are  present  also  the  signs  of  fracture  of 
the  tubercles. 

d.  Signs  of  Fracture  of  the  Humerus  through  the  Tuhercles.  Extra- 
capsular.    [Cause,  direct  blows.) 

1.  Generally,  there  is  neither  marked  mobility  nor  immobility,  ex- 
cept what  immobility  may  be  due  to  a  contusion  of  the  muscles. 

2.  Crepitus,  discovered,  but  not  so  easily  as  in  intra-capsular  frac- 
tures, by  rotating  the  arm  while  the  tubercles  are  grasped  firmly. 

3.  If  displacement  exists,  the  fragments  are  not  always  easily  kept 
in  place  when  once  reduced. 

4.  The  hand  can  be  placed  upon  the  opposite  shoulder,  with  the 
elbow  against  the  front  of  the  chest. 

5.  No  depression  under  the  acromion  process. 

6.  Head  of  the  bone  in  its  socket,  and  moving  with  the  shaft,  when, 
as  is  usually  the  case,  it  is  impacted. 

7.  Elbow  hangs  against  the  side  of  the  body. 

8.  Arm  shortened  when  impacted,  but  not  very  appreciably. 

The  signs  which  characterize  this  accident  are  more  obscure  than  in 
either  of  the  other  shoulder  accidents.  They  are  mostly  negative,  and 
will  not  generally  be  determined  positively  except  in  the  autopsy. 

e.  Signs  of  a  Longitudinal  Fracture  of  the  Head  and  Naclc,  or  splitting 
off  of  the  Greater  Tubercle.  [Cause,  direct  blow  upon  the  front  of  the 
shoulder.) 

1.  Mobility  of  the  limb  natural. 

2.  Crepitus;  elicited  especially  by  grasping  the  tubercles  and  rotat- 
ing the  arm,  or  by  carrying  it  up  and  back  and  then  rotating. 

3.  When  reduced,  the  fragments  will  not  remain  in  place. 

4.  The  hand  can  be  placed  upon  the  opposite  shoulder,  while  the 
elbow  rests  against  the  front  of  the  chest. 

5.  Some  depression  under  the  acromion  process. 

6.  A  smooth  bony  projection  directly  underneath  the  coracoid  pro- 


230  FRACTURES    OF    THE    HUMERUS. _ 

cess,  or  close  upon  its  inner  or  outer  side,  moving  with  the  shaft.  The 
head  of  the  bone  cannot  be  felt  in  the  socket,  yet  the  space  under  the 
acromion  is  not  entirely  unoccupied. 

7.  Generally,  but  not  always,  the  elbow  hangs  against  the  side. 
Sometimes  it  inclines  a  little  backwards.  It  can  always  be  easily 
brought  to  the  side. 

8.  Arm  generally  neither  lengthened  nor  shortened. 

9.  A  remarkable  increase  in  the  antero-posterior  diameter  of  the 
upper  end  of  the  bone. 

10.  A  deep  vertical  sulcus  between  the  tubercles,  corresponding  with 
the  upper  part  of  the  bicipital  groove. 

f.  Signs  of  a  Fracture  through  the  Surgical  Neck.  {Cause,  generally 
direct  blows,  but  in  old  people  frequently  caused  by  a  fall  upon  the 
elbow.) 

1.  Preternatural  mobility  often,  but  not  constantly,  present. 

2.  Crepitus,  produced  easily  when  there  is  no  impaction,  or  when 
the  displacement  is  not  complete,  but  with  difficulty  when  impaction 
exists  or  the  displacement  is  complete. 

3.  When  once  the  fragments  have  been  displaced,  it  is  exceedingly 
difficult  ever  afterward  to  maintain  them  in  place. 

4.  The  hand  can  be  easily  placed  upon  the  opposite  shoulder,  while 
the  elbow  rests  against  the  front  of  the  chest. 

5.  A  slight  depression  below  the  acromion,  not  immediately  under- 
neath its  extremity,  but  an  inch  or  more  below. 

6.  Head  of  the  bone  in  the  socket,  and  moving  with  the  shaft  when 
impacted,  but  not  moving  with  the  shaft  when  not  impacted.  The 
upper  end  of  the  lower  fragment  being  often  felt  distinctly  pressing 
upwards  toward  the  coracoid  process;  its  broken  extremity  being 
easily  distinguished  by  its  irregularity  from  the  head  of  the  bone, 

7.  Elbow  hanging  against  the  side  when  the  fragments  are  not  dis- 
placed, but  away  from  the  side  when  displacement  exists. 

8.  Length  of  arm  unchanged  unless  the  fragments  are  impacted  or 
overlapped;  or  both  fragments  are  much  tilted  inwards.  If  the  frag- 
ments are  completely  displaced,  the  arm  is  shortened. 

g.  Signs  of  a  SeparcUio7i  at  the  Epiphysis.     (  Cause,  direct  blows.) 

1.  Preternatural  immobility. 

2.  Feeble  crepitus;  less  rough  than  the  crepitus  produced  when 
broken  bones  are  rubbed  against  each  other. 

3.  Fragments  replaced  are  not  easily  maintained  in  place. 

4.  Same  as  in  preceding  variety  of  fracture. 

5.  The  depression  is  not  immediately  under  the  acromion,  yet  higher 
than  in  most  fractures  of  the  surgical  neck,  perhaps  one  inch  below 
the  acromion  process. 

6.  Head  of  the  bone  in  its  socket,  and  not  moving  with  the  shaft. 
Upper  end  of  lower  fragment  projecting  in  front,  when  displacement 
exists,  and  feeling  less  sharp  and  angular  than  in  case  of  a  broken 
bone;  indeed,  being  slightly  convex  and  rather  smooth,  it  may  easily 
be  mistaken  for  the  head  of  the  bone. 

7.  Same  as  preceding  variety. 

8.  Length  of  arm  not  changed  unless  the  fragments  are  overlapped, 


DIFFEREXTIAL    DIAGNOSIS    OF    ACCIDENTS.  231 

or  both  fragments  are  tilted  upon  each  other.  "When  the  fragments 
are  overlapped,  the  arm  is  shortened. 

9.  This  accident  is  almost  peculiar  to  infancy  and  childhood.  It 
can  seldom  occur  after  the  twentieth  year. 

There  are  other  accidents  about  the  shoulder-joint,  such  as  a  patho- 
logical partial  luxation  of  the  humerus,  dislocation  of  the  tendon  of 
the  biceps,  &c.,  which  might  possibly  be  confounded  with  fractures, 
but  the  consideration  of  which  I  shall  reserve  for  another  time. 

Treatment. — I  have  already  spoken  of  the  treatment  of  fractures  of 
the  neck  of  the  scapula,  and  my  remarks  will  now  be  confined  to  frac- 
tures of  the  upper  end  of  the  humerus. 

Fractures  of  the  Anatomical  Neck;  Intra-capsular. — As  has  already 
been  stated,  these  are  generally  compound  fractures,  and,  from  the 
extent  of  the  injury,  often  demand  resection  or  amputation  of  the  entire 
arm.  If  an  effort  is  made  to  save  the  arm,  splints  will  not  be  applied, 
and  the  treatment  will  have  little  or  no  reference  to  the  existence  of  a 
fracture ;  it  will  be  directed  only  to  the  reduction  or  prevention  of  the 
inflammation,  .&c. 

Simple  fracture  of  the  anatomical  neck,  without  any  external  wound 
communicating  with  the  joint,  and  accompanied,  as  it  often  is,  with 
impaction,  frequently  unites,  or  the  upper  fragment  becomes  encased 
in  the  lower. 

It  is  not  proper  in  such  cases  to  employ  great  violence  for  the  pur- 
pose of  detecting  crepitus,  lest  the  fragments  should  become  displaced  ; 
and  if  the  arm  should  be  found  to  be  a  little  shortened,  it  must  not  be 
extended,  with  a  view  to  overcoming  the  shortening,  since  upon  the 
impaction  probably  depend,  in  a  great  measure,  the  chances  of  union. 

The  elbow  and  forearm  may  be  suspended  in  a  sling,  while  the  arm 
is  gently  supported  against  the  side,  merely  to  insure  quietude.  No 
splints  are  necessary  or  useful. 

Treatment  of  Fractures  through  the  Tubercles  {Extra-capsular)\  Non- 
impacted  and  Impacted. — In  these  cases,  also,  the  fragments  being 
seldom  displaced,  very  little  if  any  mechanical  treatment  is  demanded. 
A  sling  is  all  that  is  usually  required.  If,  however,  on  account  of  dis- 
placement of  the  fragment,  a  splint  is  thought  necessary,  it  must  be 
applied  in  the  manner  hereafter  to  be  directed  in  cases  of  fractures  of 
the  surgical  neck. 

If  impaction,  with  shortening,  exists,  the  same  remarks  are  appli- 
cable here  as  in  intra-capsular  impacted  fractures,  namely,  that  we 
ought  not  to  rotate  the  limb  much,  nor  violently,  in  order  to  discover 
crepitus,  nor  make  extension  with  the  view  of  overeomipg  the  short- 
ening, since  the  fragments  unite  more  promptly  and  certainly  when 
the  impaction  remains,  and  its  continuance  in  no  way  damages  the 
usefulness  of  the  limb. 

Treatment  of  Longitudinal  Fracture  of  the  Head  and  Neck,  or  of  a 
Separation  of  the  Greater  Tubercle. — In  the  only  instance  which  I  have 
recognized  as  a  fracture  of  the  greater  tubercle,  and  already  referred 
to,  the  displacement  was  moderate,  and  could  not  be  overcome  either 
by  change  of  position  or  by  pressure  with  extension.  The  patient 
was  therefore  merely  laid  upon  his  back  in  bed.     No  dressings  of  any 


232  FRACTURES    OF    THE    HUMERUS. 

kind  were  employed,  and  the  fragments  seemed  to  unite  promptly, 
and  with  no  increase  in  the  displacement. 

If  the  displacement  is  originally  more  considerable,  attempts  ought 
still  to  be  made  to  reduce  the  fragments,  by  extension  and  abduction 
of  the  arm,  with  direct  pressure;  yet  they  will  not  generally  prove 
completely  successful,  nor  will  it  be  found  easy  to  retain  them  when 
reduced. 

Mr.  Mayo  treated  a  fracture  of  this  character,  which  occurred  in  a 
man  of  sixty  years  of  age,  with  a  figure-of-8  bandage,  and  a  sling,  with 
a  lathe  splint  on  the  outer  side  of  the  humerus,  the  upper  part  of 
which  was  made  to  bear  on  the  fragments,  by  uniting  the  upper  part 
of  the  circular  arm  roller  to  the  figure-of-8  bandage.  "  The  fracture 
united  favorably,"  he  says,  but  we  presume  that  he  does  not  mean  to 
affirm  that  it  united  without  any  degree  of  displacement;  a  result 
which,  probably,  ought  never  to  be  expected.  Mr.  Mayo  adds,  how- 
ever, that  "  for  a  long  time  the  patient  had  some  difficulty  in  carrying 
the  arm  backward."^ 

Treatment  of  Fractures  of  the  Surgical  Neck,  including  Separations  at 
the  Epiphysis. — I  see  no  reason  to  suppose  that  the  indications  of  treat- 
ment can  essentially  vary  in  separations  at  the  epiphysis,  from  those 
in  true  fractures  through  any  part  of  the  surgical  neck,  since  the  rela- 
tive action  of  the  muscles  remains  the  same,  and  the  direction  of  the 
displacement  is  generally  the  same.  My  remarks,  therefore,  upon  this 
point  may  be  considered  as  equally  applicable  to  fractures  and  epiphy- 
sary  separations. 

In  a  considerable  proportion  of  these  cases  not  much  displacement 
of  either  fragment  takes  place,  and  consequently  we  have  only  to  apply 
such  moderate  retentive  means  as  will  insure  quiet.  Indeed,  under 
such  circumstances  we  might  not  hesitate  to  adopt  the  posture  treat- 
ment practised  by  Dupuytren  in  two  cases,  both  of  which  terminated 
favorably.  The  treatment  consisted  in  placing  the  arm,  semi-flexed, 
on  a  pillow,  the  pillow  being  arranged  so  as  to  form  a  pyramid,  the 
summit  of  which  was  lodged  in  the  axilla,  while  the  elbow  was  se- 
cured to  the  side  of  the  body  by  a  bandage.^ 

Unhappily,  however,  as  we  have  seen,  this  condition  is  not  always 
present ;  the  most  frequent  form  of  displacement  being  that  in  which 
the  lower  fragment  is  drawn  upwards  and  inwards,  or  towards  the 
coracoid  process. 

In  such  cases  it  will  require,  often,  no  little  perseverance  and  skill 
to  effect  reduction,  if  it  is  not  found  to  be  actually  impossible,  and 
still  more  to  retain  the  bones  in  place  when  once  reduced.  Indeed, 
it  is  proper  to  say  that  a  complete  reduction  is  seldom  accomplished 
and  permanently  maintained,  owing,  probably,  to  the  advantageous 
action  of  the  muscles  which  tend  to  produce  the  displacement,  and  in 
part  also  to  the  difficulty  of  applying  any  apparatus  or  dressing  which 
shall  act  efficiently  upon  the  fragments. 

Sir  Astley  Cooper  recommends  for  this  accident  a  couple  of  splints, 

'  B.  Cooper's  edition  of  Sir  A.  Cooper  on  Dislocations,  «fec.,  American  edition, 
p.  835. 
^^  Dupuytren  on  Bones,  Sydenliam  edition,  p.  99. 


FRACTUEES    THROUGH    THE    SURGICAL    NECK, 


233 


to  be  placed  one  in  front  of  and  one  behind  the  shoulder,  an  axillary 
pad,  a  clavicular  bandage,  and  a  sling ;  the  sling  being  made  to  sus- 
pend only  the  wrist  and  not  the  elbow,  since  he  had  observed  that 
when  the  elbow  was  lifted  the  upper  end  of  the  shaft  was  inclined  to 
fall  forwards. 

Mr.  Tyrrell  informed  Mr.  Cooper  that  in  a  similar  case  he  had  found 
the  bone  best  maintained  in  its  natural  position  by  its  being  raised 
and  supported  at  right  angles  with  the  side,  by  a  rectangular  splint,  a 
part  of  which  rested  against  the  side,  while  the  arm  reposed  upon  the 
other  part;  and  until  he  had  made  use  of  this  plan,  he  could  not 
succeed  in  removing  the  deformity,  or  in  keeping  the  bone  in  its 
place. 

Mr.  Erichsen  has  found  a  very  convenient  apparatus  to  consist  of 
"  a  leather  splint  about  two  feet  long  by  six  inches  broad,  bent  upon 
itself  in  the  middle,  so  that  one-half  of  it  may  be  applied  lengthwise 
to  the  chest,  and  the  other  half  to  the  inside  of  the  injured  arm,  the 
angle  formed  by  the  bend,  which  should  be  somewhat  obtuse,  being 
well  pressed  up  into  the  axilla." 

The  following  is  the  plan  which  I  would,  however,  generally  re- 
commend : — 

The  fragments  having  been  reduced  as  completely  as  possible,  a 
broad  and  firm  gutta-percha  splint  should  be  moulded  to  the  outside 
of  the  arm  and  shoulder.     When  it  has  become  sufficiently  hard  and 


Fis;.  64. 


Fia;.  65. 


Fig.  66. 


Welch's  arm  splint. 


Plan  of  author's  leather 
arm  splint. 


Leather  splint  closed  at  top, 
and  complete. 


firm,  it  may  be  secured  in  place  by  a  roller  carried  from  the  elbow  to 
the  axilla.  If  the  splint  covers  well  the  top  of  the  shoulder,  and  is 
sufficiently  wide,  it  is  not  apt  to  become  displaced ;  and  by  resting 
against  the  point  of  the  acromion  process,  it  enables  the  upper  turns 
of  the  bandage  to  draw  the  broken  end  of  the  lower  fragments  out- 
wards ;  at  least,  as  effectually  as  any  other  dressing  is  capable  of  doing, 
and  renders  an  axillary  pad  unnecessary.  The  sling  may  then  be 
16 


234  FRACTURES    OF    THE    HUMERUS. 

applied  as  recommended  by  Sir  Astley  Cooper,  or  the  arm  may  be 
permitted  to  hang  perpendicularly  beside  the  body.  The  clavicular 
bandage,  also  recommended  by  Sir  Astley,  complicates  the  dressing 
very  much,  and  does  not  seem  to  me  to  answer  any  very  useful  pur- 
pose ;  while  the  axillary  pad  exposes  the  brachial  plexus  to  painful 
if  not  injurious  pressure. 

As  a  substitute  for  gutta-percha,  a  firm  sheet  of  felt  may  be  em- 
ployed, a  piece  of  sole-leather  or  a  carved  wooden  splint,  or  the  very 
complete  shoulder  and  arm  splint  of  Welch  ;  but  in  either  case  the 
upper  portion  of  the  splint  ought  always  to  rest  upon  the  shoulder,  so 
as  to  prevent  its  sliding  downwards. 

§  5.  Shaft,  below  the  Surgical  Neck  and  above  the  Base  of  the 

Condyles. 

Causes. — In  a  record  of  nineteen  cases  in  which  the  cause  of  the  frac- 
ture is  stated,  I  find  this  portion  of  the  shaft  broken  from  direct  violence 
twelve  times ;  from  indirect  blows,  the  concussion  being  received  upon 
the  elbow,  twice;  once  it  was  a  consequence  of  tertiary  lues,  once  it 
occurred  during  birth,  and  three  times  in  the  same  patient  it  has  been 
broken  from  muscular  action  alone,  each  consecutive  fracture  occur- 
ring at  a  different  point.  The  records  of  surgery  furnish  many  ex- 
amples of  fracture  of  the  shaft  of  the  humerus  from  muscular  action, 
as  in  throwing  a  stone  or  snowball ;  but  the  most  singular  examples 
are  those  in  which  the  bone  has  been  broken  in  a  trial  of  strength 
between  two  persons,  by  grasping  the  hands  palm  to  palm,  with  the 
elbows  resting  upon  a  table,  and  twisting,  when  the  humerus  has  sud- 
denly given  way  a  little  above  the  condyles.  This  practice  is  called 
by  the  French  "  tourner  poignet,''''  the  game  of  turning  wrists.  I  have 
seen  one  case  of  this  kind,  which  was  under  the  care  of  Dr.  Winne, 
and  Malgaigne  has  collected  five  other  similar  cases,  two  of  which 
were  reported  by  Lonsdale.  In  Z'  Unio^t  Medicale  is  reported  an  ex- 
ample in  which  the  fracture  occurred  on  a  level  with  the  insertion  of 
the  deltoid,  a  little  below  the  insertion  of  the  pectoralis  major  and 
latissimus  dorsi.     The  fracture  seemed  to  be  nearly  transverse.' 

The  example  of  fracture  during  birth,  to  which  I  have  referred, 
occurred  in  a  healthy  female  child,  whose  parents  were  also  healthy. 
The  mother  was  in  labor  six  or  eight  hours,  but  the  labor  was  not 
severe.  She  was  attended  by  a  midwife,  and  does  not  know  whether 
violence  was  employed  or  not.  Dr.  Lockwood,  of  Bufiialo,  was  called 
on  the  third  day,  and  found  the  arm  broken  a  little  below  its  middle, 
and  moving  as  freely  as  it  did  at  the  elbow-joint ;  he  applied  lateral 
splints  with  bandages,  &c.  I  saw  the  child  with  Dr.  Lockwood  on 
the  seventeenth  day  after  its  birth.  There  was  then  a  perfect  ferule 
of  ensheathing  callus  surrounding  the  fragments,  and  which,  owing  to 
the  softness  of  the  flesh,  could  be  easily  detected  and  defined.  The 
fragments  had  been  firm  at  least  three  or  four  days.     Nearly  a  year 

'  Amer.  Med.  Times,  toI.  iv.  p.  153. 


SHAFT  BELOW  THE  SURGICAL  NECK.         235 

after,  I  again  examined  the  arm,  and  could  not  discover  any  traces  of 
the  accident. 

Dr.  Lowenhardt  has  also  reported  a  case  in  which  the  evidence  was 
conclusive  that  the  fracture  was  caused  solely  by  the  contractions  of 
the  uterus,  which  forced  the  arm  against  the  pubes;  the  arm  being 
heard  distinctly  to  snap  when  it  was  passing  this  point  and  while  the 
hands  of  the  accoucheur  were  not  aiding  in  the  delivery.  In  this  case 
the  humerus  was  broken  in  its  upper  third.^ 

Dr.  N.  Fanning,  of  Catskill,  N.  Y.  has  reported  to  me  the  following 
as  having  occurred  in  his  own  practice : — 

"  Mrs.  H.,  of  Catskill,  was  delivered  June  8,  1865,  after  a  short  and 
not  severe  labor,  of  a  full-grown  and  healthy  male  child.  The  mother 
was  well  formed,  with  ample  pelvis.  The  labor  was  natural,  and  the 
presentation  the  most  favorable,  the  occiput  corresponding  to  the  left 
acetabulum  ;  but  immediately  after  the  delivery  of  the  head,  a  hand  and 
a  portion  of  the  forearm  of  the  child  were  felt  above  the  pubes.  The 
shoulders  and  body  were  delivered  very  quickly  after  the  head,  and 
during  a  single  pain.  Just  as  the  right  shoulder  of  the  child  was  pass- 
ing under  the  arch  of  the  pubes,  I  heard  a  snap,  not  unlike  that  caused 
by  the  breaking  of  a  pipe-stem,  which  I  soon  found,  as  I  suspected, 
to  be  caused  by  the  fracture  of  the  right  os  humeri  of  the  child  in  its 
upper  third."     The  bone  united  with  some  deformity. 

Dr.  Fanning  is  of  the  opinion  that,  in  this  case,  the  contraction  of 
the  uterus,  occurring  while  the  arm  of  the  child  occupied  some  un- 
usual position,  was  the  cause  of  the  fracture.  It  was  certainly  not 
due  to  any  force  applied  by  Dr.  Fanning  himself. 

Seat  and  Direction  of  the  Fracture. — The  seat  of  the  fracture  is  more 
often  below  than  above  the  middle  of  the  bone ;  thus,  I  have  found  the 
fracture  fourteen  times  near  the  middle,  andt*he  same  number  of  times 
below  the  middle  third,  but  only  seven  times  above  the  middle  third. 
The  observations  of  Norris,  who  found  four  fractures  of  the  shaft 
above  the  middle,  and  nine  below,  correspond  with  my  own  ;^  but 
M.  Gueretin,  in  the  same  number  of  fractures,  found  nine  above  the 
middle  and  four  below.^ 

The  line  of  fracture  is  generally  oblique,  but  more  often  transverse 
than  in  fractures  of  the  clavicle,  femur,  or  tibia. 

Displacement. — The  direction  of  the  displacement  depends,  no  doubt, 
sometimes  upon  the  precise  point  of  the  fracture  and  upon  the  action 
of  the  muscles  operating  upon  the  two  fragments ;  thus,  if  the  fracture 
takes  place  just  above  the  insertion  of  the  deltoid,  the  lower  fragment 
is  liable  to  be  drawn  upwards  and  outwards,  in  the  direction  of  its 
fibres,  while  the  upper  fragment  is  carried  toward  the  origin  of  the 
pectoralis  major,  &c. ;  but,  in  a  great  majority  of  cases,  the  influence 
of  these  muscles  is  more  than  counterbalanced  by  the  direction  of  the 
force,  and  by  the  direction  of  the  fracture.  Practically,  therefore,  it  is 
seldom  of  much  importance  to  determine  the  exact  point  of  fracture, 

'  Lowenhardt,  American  Journal  of  the  Medical  Sciences,  January,  1841,  p.  250, 
from  Medicin.  Zeit.,  Mai  6, 1840. 
*  Norris,  Am.  Journ.  of  Med.  Sci.,  January,  1842,  vol.  xix.  p.  28. 
^  Gueretin,  Presse  Medicale,  vol.  i.  p.  45. 


236  FRACTUEES    OF    THE    HUMERUS. 

as  to  whether  it  is  just  above  or  below  the  insertion  of  a  particular 
muscle  ;  nor,  indeed,  is  it  generally  very  easy  to  ascertain  this  point 
with  much  precision. 

The  amount  of  displacement  varies  considerably  in  different  persons, 
and  in  fractures  at  different  points,  but  it  will  average  about  three- 
quarters  of  an  inch.  When  the  fracture  is  produced  by  muscular 
action  alone,  it  is  generally  transverse,  and  displacement  seldom  occurs. 
Such  was  the  fact  in  every  instance  where  my  own  patient  broke  the 
arm  three  times  consecutively  at  difierent  points ;  and  union  was 
speedily  accomplished,  and  with  no  deformity.  Dupuytren,  however, 
saw  a  case  which  constituted  i\n  exception  to  this  general  rule.  The 
fragments  became  completely  separated,  and  were  so  movable  that 
union  could  not  be  effected,  and  he  was  compelled,  after  three  months, 
to  resort  to  resection. 

Results. — In  twenty-three  examples,  the  average  shortening  is  about 
one-quarter  of  an  inch  ;  but  of  these,  thirteen  are  not  shortened  at  all, 
so  that  the  average  of  shortening  in  the  remaining  ten  is  three-quar- 
ters of  an  inch;  the  amount  of  overlapping  varying  from  one-quarter 
of  an  inch  to  one  inch  and  a  quarter. 

In  forty-five  examples,  not  including  gunshot  fractures,  I  have  three 
times  seen  the  humerus  refuse  to  unite  by  bone ;  once  when  the  fracture 
was  in  the  lower  third  of  the  shaft.  This  was  an  oblique,  compound 
fracture,  and  no  union  had  taken  place  at  the  end  of  five  months.  The 
man  was  intemperate,  but  in  pretty  good  health.^  In  the  second  case, 
the  fracture  had  occurred  a  little  below  the  middle  of  the  bone,  and 
it  was  simple.  Five  months  after  the  accident  this  patient  consulted 
me,  when  I  found  the  elbow  anchylosed,  the  forearm  being  fixed  at 
right  angles  with  the  arm.^  Neither  of  these  patients  had  been  under 
my  care  previously,  but  I  learned  that  an  intelligent  Canadian  surgeon 
had  treated  one  of  them,  and  the  other  had  been  seen  and  treated  by 
several  surgeons. 

In  the  third  case,  a  lad,  five  years  of  age,  received  a  fracture 
about  three  or  four  inches  above  the  elbow-joint,  by  the  passage  across 
the  limb  of  a  heavy  army  wagon.  The  arm  was  dressed  with  splints, 
and  in  about  five  weeks  several  fragments  of  necrosed  bone  were 
removed  by  Dr.  Pope,  of  St.  Louis,  and  the  splints  were  again  applied. 
"J'en  months  from  the  date  of  the  injury,  Dr.  Brinton,  of  Philadelphia, 
operated  by  perforation,  and  reapplied  splints.  When  the  splints  were 
removed,  the  limb  was  straight  and  apparently  firm,  but  the  bond  of 
union  gradually  gave  way,  and  when  he  came  under  my  charge  in 
Kov.  1864,  more  than  two  years  after  the  accident,  the  arm  was  bent 
at  an  angle  of  45°,  and  the  union  was  fibrous  only.  Under  my  advice 
all  restraint  and  dressings  were  removed,  and  he  was  sent  into  the 
country  to  improve  his  general  health,  with  the  understanding  that 
I  would  operate  at  some  future  day.  Subsequently,  on  the  14th  of 
April,  1867,  I  resected  the  bone  at  the  seat  of  fracture,  securing  the 
fragments  with  wire,  and  supporting  the  arm  with  a  gutta-percha 
splint.     The  result  was  a  perfect  bony  union,  and  a  very  useful  arm. 

1  Report  on  Deformities,  &c.,  Case  33.  ^  ibid.,  Case  31. 


SHAFT  BELOW  THE  SURGICAL  NECK. 


23; 


Fig.  67. 


In  two  other  cases,  the  elbow  remained  somewhat  stiff'  a  long  time 
after  the  splints  were  removed ;  in  one  case,  complete  freedom  of 
motion  was  not  restored  at  the  end  of  fifteen  years. 

Generally,  however,  the  motions  of  the  elbow-joint  have  been  very 
soon  restored  after  the  removal  of  the  splints  and  sling. 

I  ought  to  mention  that,  not  unfrequently,  fractures  of  the  shaft  of 
the  humerus,  and  especially  where  they  are  occasioned  by  direct  blows, 
are  followed  by  great  swelling,  and  sometimes  by  abscesses.  In  one 
instance,  the  fracture  having  taken  place  within  the  insertion  of  the 
deltoid  muscle,  the  sharp  extremity  of  the  lower  fragment  was  made 
to  penetrate  the  flesh,  causing  an  abscess,  and  finally  tetanus,  of  which 
my  patient  soon  died. 

The  following  remarks  of  Malgaigne  are  too  pertinent  to  be  omitted 
in  this  connection:  "When  there  is  great  obliquity,  with  overlapping, 
or  a  fracture  with  splintering,  or  a  multiple  frac- 
ture, a  certain  amount  of  deformity  is  inevitable, 
and  the  formation  of  callus  demands  one  or  two 
weeks  more.  With  the  inflammation  comes  also 
the  danger  of  suppuration,  and  later,  a  rigidity  of 
the  articulations  difficult  to  dissipate.  In  short, 
we  must  not  forget  that  of  all  fractures,  those  of  the 
humerus  are  most  liable  to  fail  of  consolidation." 

On  the  other  hand,  we  shall  find,  in  the  case  of 
this  bone,  as  in  all  others,  some  remarkable  excep- 
tions, where,  although  the  fracture  may  be  com- 
pound, and  badly  comminuted,  yet  the  limb  has 
been  saved  and  made  useful. 

Treatment. — In  the  treatment  of  fractures  of  that 
portion  of  the  shaft  of  the  humerus  now  under 
consideration,  I  have  preferred  generally  a  broad 
and  thick  splint  of  sole-leather — felt,  or  gutta-percha, 
may  answer  as  well — sufficiently  long  to  extend 
from  the  top  of  the  shoulder  to  the  elbow-joint, 
moulded  accurately,  and  applied  to  the  outside  of 
the  shoulder  and  arm,  while  the  limb  is  flexed  to 
a  right  angle,  and  while  extension  is  being  made 
upon  the  humerus.  This  being  properly  padded, 
and  secured  in  place  by  rollers,  I  place  the  arm  in 
a  sling  beside  the  body.  The  sling  must,  however, 
be  so  arranged,  by  being  looped  under  the  wrists,  and  not  under  the 
elbow,  as  that  the  weight  of  the  elbow  and  lower  part  of  the  arm  may 
aid  in  making  extension. 

Other  surgeons  have  sought  to  make  permanent  extension  in  these 
and  certain  other  fractures  of  the  humerus,'  by  various  contrivances. 
Mr.  Lonsdale  constructed  an  instrument  which  might  be  lengthened 
or  shortened  to  suit  the  case;  it  was-made  of  steel,  and  was  worked 
with  a  screw  operating  upon  cogs  in  a  sliding  bar;  resembling,  in 
some  respects,  the  arm  portion  of  Jarvis'  adjuster.  In  the  second 
London  edition  of  a  series  of  plates  illustrating  the  action  of  the 


Lonsdale's  extension 

APPARATUS.— A. Cnitcli. 
B.  Shaft.  C.  Elbow  rest. 
E.  Hook  for  attacliment 
of  bandage,  opposite 
which  is  a  cro-ssbar  for 
the  same  purpose. 


238 


FRACTUEES    OF    THE    HUMERUS. 


muscles  in  producing  displacement  in  fractures,  by  S.  W.  Hind,  is  a 
drawing  of  an  apparatus  invented  by  the  author  for  the  same  purpose, 
which  is  very  simple,  and  in  some  respects  more  complete  than  Lons- 
dale's, and  which  may  be  easily  adapted  to  almost  any  form  of  arm- 
splint.  Indeed,  nothing  more  is  necessary  than  to  attach  to  the  ordi- 
nary long  splint  a  movable  crutch. 

Dr.  Henry  A.  Martin,  of  Boston,  has  invented  a  splint,  also  for  the 
purpose  of  making  extension  in  fractures  of  the  humerus,  the  counter- 
extension  being  made,  by  adhesive  plasters,  from  the  side  of  the  chest. 

Fiff.  68. 


H.  A.  Martin's  extension  in  fractures  of  the  humerus. 


The  apparatus  is  elongated  by  a  ratchet  operating  upon  two  steel  bars, 
which  are  thus  made  to  move  upon  each  other.  I  have  never  been 
able  to  make  reliable  counter-extension  from  the  walls  of  the  chest 
for  any  purpose  whatever ;  but  this  method  is  at  least  not  likely  to 
do  any  harm,  as  there  is  no  pressure  upon  the  axillary  nerves.  The 
plan  may  therefore  deserve  a  trial. 

Dr.  E.  A.  Clark,  of  the  St.  Louis  City  Hospital,  has  proposed  to 
accomplish  the  extension,  in  fractures  of  the  head  and  surgical  neck, 
by  suspending  a  weight  from  the  elbow.  He  reports  one  case  suc- 
cessfully treated  by  this  method.  When  the  patient  is  in  the  recum- 
bent  posture,  the  weight   must  be  suspended  over   a  pulley.     No 


SHAFT  BELOW  THE  SURGICAL  NECK. 


239 


doubt  this  is  the  only  method  by  which  Fig.  69. 

really  effective  extension  can  ever  be 
made  in  fractures  of  the  humerus,  and 
there  may  be  perhaps  examples  of  frac- 
tures of  the  neck  of  the  humerus  in 
which  the  fragments  overlap  persistent- 
ly, where  it  will  be  proper  to  resort  to 
this  novel  expedient.  When  fractures 
occur  above  the  deltoid,  the  overlapping 
is  often  excessive,  and  there  is  not  much 
danger  of  their  being  forcibly  separa- 
ted by  the  extension;  but  in  fractures 
below  this,  Dr.  Clark's  method  would 
expose  to  the  danger  of  separation  and 
non-union  of  the  fragments.  As  em- 
ployed for  fractures  of  the  neck,  no 
splints  are  used  by  Dr.  Clark ;  yet  as  a 
means  of  holding  the  lower  fragment 
out,  a  single  outside  splint  might  be 
useful. 

I  believe  that  all  these  contrivances 
may  prove  occasionally  useful,  but  the 
common  experience  of  surgeons  has 
shown  how  difficult  it  is  to  accomplish 
much  extension  by  means  of  pressure  in 
the  axilla;  a  mode,  too,  which  I  think 
must  be  wholly  inadmissible  when  the 
fracture  approaches  the  upper  end,  since 

the  pressure  by  the  crutch-head  upon  the  pectoralis  major  and  latis- 
simus  dorsi,  which  constitute  the  margins  of  the  axilla,  must  tend  to 
displace  the  fragments  upon  which  they  act,  inwardly,  and  which 
seldom  can  be  applied  with  much  force  to  fractures  near  the  con- 
dyles, on  account  of  the  probable  existence  of  inflammation  and  swell- 
ing about  the  joint. 

Malgaigne,  when  speaking  of  the  apparatus  of  Lonsdale,  remarks : 
"But  the  surgeon  should  never  lose  sight  of  the  fact  that  permanent 
extension  is  a  resource  always  dangerous,  often  useless,  and  which 
demands  in  its  application  much  caution  and  watchfulness." 

The  following  example  will  illustrate  the  practical  difficulty  of  em- 
ploying permanent  extension  in  fractures  of  the  humerus : — 

A  laborer,  aged  thirty,  was  admitted  into  the  Buffalo  Hospital  of  the 
Sisters  of  Charity,  on  the  second  day  of  October,  1853,  with  a  simple 
oblique  fracture  of  the  humerus,  which  had  occurred  three  days  before. 
The  fracture  was  situated  within  the  insertion  of  the  deltoid,  and  hav- 
ing been  produced  by  the  rolling  of  a  log  upon  the  arm,  the  whole 
limb  was  much  swollen.  The  night  following  his  admission,  in  a  fit 
of  delirium  tremens,  he  removed  all  of  the  dressings.  When  I  visited 
the  wards  in  the  morning,  I  found  the  fragments  displaced  and  the 
muscles  contracting  violently.  The  ordinary  dressings  were  applied, 
and  continued  until  the  fifth  day,  when,  as  the  delirium  had  not  ceased, 


Clark's  extension    in  fractures  of  the 
neck  of  the  humerus. 


240  .      FRACTUKES    OF    THE    HUMERUS. 

and  the  muscles  continued  to  contract  witla  great  violence,  it  was  de- 
termined to  attempt  permanent  extension.  For  this  purpose  we  lifted 
the  elbow  upwards  and  outwards,  to  relax  the  deltoid,  and  then, 
having  made  extension  with  the  forearm  placed  at  a  right  angle  with 
the  arm,  we  fitted  carefully  a  large  gutta-percha  splint  to  the  forearm, 
arm,  axilla,  and  side,  in  such  a  manner  that  when  the  splint  was 
secured  to  these  several  parts,  the  arm  could  not  fall  to  the  side  of  the 
body  completely,  and  in  proportion  as  it  did  fall  downward,  it  would 
make  extension  upon  the  arm.  This  splint  was  well  padded,  and 
secured  in  place  by  rollers. 

On  the  sixth  day  the  delirium  had  ceased,  and  never  returned. 
The  dressings  were  well  in  place,  and  seemed  to  accomplish  the  indi- 
cation we  had  in  view ;  but,  on  the  seventh  day,  although  he  had  kept 
very  quiet,  everything  was  disarranged,  and  the  whole  had  to  be  re- 
adjusted. On  the  eighth  and  ninth  the  same  thing  occurred.  During 
this  time  we  had  varied  the  dressings,  position,  &c.,  each  day,  to  meet, 
if  possible,  the  difficulties;  but  it  was  at  length  deemed  unwise  to 
pursue  the  attempt  any  farther,  and  we  returned  to  the  use  of  the 
ordinary  splints,  laying  the  arm  against  the  side  of  the  body.  The 
union  was  finally  completed  without  either  overlapping  or  angular 
displacement. 

Something  may  always  be  accomplished,  when  the  patient  is  walking 
about,  by  allowing  the  elbow  to  escape  from  the  sling,  so  that  its 
weight  shall  make  constant  traction  upon  the  lower  fragment;  and  the 
plan  which  I  suggested  some  years  since,  of  treating  certain  cases  of 
delayed  union  of  the  humerus,  namely,  extending  the  arm  at  full 
length  by  the  side  of  the  body,  so  that  the  lower  fragment  shall  re- 
ceive the  whole  weight  of  the  forearm  and  hand,  might  occasionally 
prove  valuable  in  recent  fractures  where  the  tendency  to  override 
was  very  great.  In  three  instances,  I  have  already  put  this  plan 
sufficiently  to  the  test  to  determine  its  safety  and  utility. 

The  precise  plan,  and  my  reasons  for  its  adoption  in  certain  cases 
of  delayed  union,  were  set  forth  in  the  following  paper,  read  before 
the  Buffalo  City  Medical  Association,  and  published  in  the  Buffalo 
Medical  Journal  for  August,  1854. 

"I  have  observed  that  non-union  results  more  frequently  after  frac- 
tures of  the  shaft  of  the  humerus,  than  after  fractures  of  the  shaft  of 
any  other  bone. 

"  Comparing  the  humerus  with  the  femur,  between  which,  above  all 
others,  the  circumstances  of  form,  situation,  &c.,  are  most  nearly 
parallel,  and  in  both  of  which  non-union  is  said  to  be  relatively  fre- 
quent, I  find  that  of  forty-nine  fractures  of  the  humerus,  four  occurred 
through  the  surgical  neck,  twelve  through  the  condyles,  and  twenty- 
nine'  through  the  shaft.  In  one  of  the  twenty-nine  the  patient  survived 
the  accident  only  a  few  days.  In  four  of  the  remaining  twenty-eight 
union  had  not  occurred  after  the  lapse  of  six  months,  and  in  many 
more  it  was  delayed  beyond  the  usual  time.  Two  of  the  four  were 
simple  fractures,  and  occurred  near  the  middle  of  the  humerus;  the 
third  was  compound,  and  occurred  near  the  middle  also ;  the  fourth 
was  compound,  and  occurred  near  the  condyles. 


SHAFT    BELOW    THE    SUEGICAL    NECK.  241 

"  This  analysis  supplies  us,  therefore,  with  four  cases  of  non-union, 
from  a  table  of  twenty-eight  cases  of  fractures  through  the  shaft. 

"  Of  eighty-seven  fractures  of  the  femur,  twenty  occurred  through 
the  neck,  one  through  the  trochanter  major,  and  one  through  the  con- 
dyles. The  remaining  sixty-five  occurred  through  the  shaft,  and 
generally  near  the  middle,  and  not  in  one  case  was  the  union  delayed 
"beyond  six  months. 

"  To  make  the  comparison  more  complete,  I  must  add  that  of  the 
twenty-eight  fractures  of  the  shaft  of  the  humerus,  six  were  compound; 
and  of  the  sixty-five  fractures  of  the  shaft  of  the  femur,  six  were 
either  compound,  comminuted,  or  both  compound  and  comminuted. 
The  six  compound  fractures  of  the  shaft  of  the  humerus  furnished  two 
cases  of  non-union.  The  six  cases  of  either  compound  or  comminuted, 
or  compound  and  comminuted  fractures  of  the  femur,  furnished  no 
case  of  non-union. 

"  I  beg  to  suggest  to  the  Society  what  seems  to  me  to  be  the  true 
explanation  of  these  facts. 

"  It  is  the  universal  practice,  so  far  as  I  know,  in  dressing  fractures 
of  the  humerus,  to  place  the  forearm  at  a  right  angle  with  the  arm. 
Within  a  few  days,  and  generally,  I  think,  within  a  few  hours,  after 
the  arm  and  forearm  are  placed  in  this  position,  a  rigidity  of  the  mus-  , 
cles  and  other  structures  has  ensued,  and  to  such  a  degree  that  if  the 
splints  and  sling  are  completely  removed,  the  elbow  will  remain  flexed 
and  firm  ;  nor  will  it  be  easy  to  straighten  it.  A  temporary  false  an- 
chylosis has  occurred,  and  instead  of  motion  at  the  elbow-joint,  when 
the  forearm  is  attempted  to  be  straightened  upon  the  arm,  there  is 
only  motion  at  the  seat  of  fracture.  It  will  thus  happen  that  every 
upward  and  downward  movement  of  the  forearm  will  inflict  motion 
upon  the  fracture ;  and  inasmuch  as  the  elbow  has  become  the  pivot, 
the  motion  at  the  upper  end  of  the  lower  fragment  will  be  the  greater 
in  proportion  to  the  distance  of  the  fracture  from  the  elbow-joint. 

"No  doubt  it  is  intended  that  the  dressings  shall  prevent  all  motion 
of  the  forearm  upon  the  arm ;  but  I  fear  that  they  cannot  always  be 
made  to  do  this.  I  believe  it  is  never  done  when  the  dressing  is 
made  without  angular  splints,  nor  is  it  by  any  means  certain  that  it 
will  be  accomplished  when  such  splints  are  used.  The  weight  of  the 
forearm  is  such,  when  placed  at  a  right  angle  with  the  arm,  and  en- 
cumbered with  splints  and  bandages,  that  even  when  supported  by  a 
sling,  it  settles  heavily  forwards,  and  compels  the  arm-dressings  to 
loosen  themselves  from  the  arm  in  front  of  the  point  of  fracture,  and 
to  indent  themselves  in  the  skin  and  flesh  behind.  By  these  means 
the  upper  end  of  the  lower  fragment  is  tilted  forwards.  If  the  fore- 
arm should  continue  to  drag  upon  the  sling,  nothing  but  a  permanent 
forward  displacement  would  probably  result.  The  bones  might  unite, 
yet  with  a  deformity, 

"But  the  weight  of  the  forearm  under  these  circumstances  is  not 
uniform,  nor  do  I  see  how  it  can  be  made  so.  It  is  to  the  sling  that 
we  must  trust  mainly  to  accomplish  this  important  indication.  But 
you  have  all  noticed  that  the  tension  or  relaxation  of  the  sling  depends 
upon  the  attitude  of  the  body,  whether  standing  or  sitting  ;  upon  the 


242  FRACTURES    OF    THE    HUMERUS. 

erection  or  inclination  of  the  bead;  upon  the  motions  of  the  shoulders; 
and  in  no  inconsiderable  degree  upon  the  actions  of  respiration.  Nor 
does  the  patient  himself  cease  to  add  to  these  conditions  by  lifting  the 
forearm  with  his  opposite  hand  whenever  provoked  to  it  by  a  sense 
of  fatigue. 

"  This  difficulty  of  maintaining  quiet  apposition  of  the  fragments 
while  the  arm  is  in  this  position,  at  whatever  point  it  may  be  broken, 
becomes  more  and  more  serious  as  we  depart  from  the  elbow-joint, 
and  would  be  at  its  maximum  at  the  upper  end  of  the  humerus,  were 
it  not  that  here  a  mass  of  muscles,  investing  and  adhering  to  the  bone, 
in  some  measure  obviates  the  difficulty.  Its  true  maximum  is,  there- 
fore, near  the  middle,  where  there  is  less  muscular  investment,  and 
where,  on  the  one  hand,  the  fracture  is  sufficiently  remote  from  the 
pivot  or  fulcrum  to  have  the  motion  of  the  upper  end  of  the  lower 
fragment  multwplied  through  a  long  arm,  while  on  the  other  hand,  it 
is  sufficiently  near  the  armpit  and  shoulder  to  prevent  the  upper 
portion  of  the  splint  and  arm-dressings  from  obtaining  a  secure  grasp 
upon  the  lower  end  of  the  upper  fragment. 

"It  must  not  be  overlooked  that  the  motion  of  which  we  speak 
belongs  exclusively  to  the  lower  fragment,  and  that  it  is  always  in 
the  same  plane  forwards  and  backwards,  but  especially  that  it  is  not 
a  motion  upon  the  fracture  as  upon  a  pivot,  but  a  motion  of  one  frag- 
ment to  and  from  its  fellow.  This  circumstance  I  regard  as  important 
to  a  right  appreciation  of  the  difficulty.  Motion  alone,  I  am  fully 
convinced,  does  not  so  often  prevent  union  as  surgeons  have  generally 
believed.  It  is  exceedingly  rare  to  see  a  case  of  non-union  of  the 
clavicle.  Of  forty-seven  cases  of  fracture  of  the  clavicle  which  have 
come  under  my  observation,  and  in  by  far  the  greater  proportion  of 
which  considerable  overlapping  and  consequent  deformity  ensued, 
only  one  has  resulted  in  non-union,  and  in  this  instance  no  treatment 
whatever  was  practised,  but  from  the  time  of  the  accident  the  patient 
continued  to  labor  in  the  fields,  and  hold  the  plough  as  if  nothing  had 
occurred.  I  have,  therefore,  seen  no  case  of  non-union  of  the  clavicle 
where  a  surgeon  has  treated  the  accident.  Indeed,  what  is  most  per- 
tinent and  remarkable,  its  union  is  more  speedy,  usually,  than  that  of 
any  other  bone  in  the  body  of  the  same  size.  Yet  to  prevent  motion 
of  the  fragments  in  a  case  of  fractured  clavicle  with  complete  separa- 
tion and  displacement,  except  where  the  fracture  is  near  one  of  the 
extremities  of  the  bone,  I  have  always  found  wholly  impracticable. 
Wherever  bandages  or  apparatus  has  been  applied,  I  have  still  seen 
always  that  the  fragments  would  move  freely  upon  each  other  at  each 
act  of  inspiration  and  expiration,  and  at  almost  every  motion  of  the 
head,  body,  or  upper  extremities.  It  is  probable,  gentlemen,  that  you 
have  made  the  same  observation. 

"From  this  and  many  similar  facts  I  have  been  led  to  suspect,  for 
a  long  time,  that  motion  has  had  less  to  do  with  non-union  than  was 
generally  believed. 

"  I  find,  however,  no  difficulty  in  reconciling  this  suspicion  with 
my  doctrine  in  reference  to  the  case  in  question;  and  it  is  precisely 


SHAFT  BELOW  THE  SURGICAL  NECK.         243 

because,  as  I  have  already  explained,  the  motion,  in  case  of  a  fractured 
humerus,  dressed  in  the  usual  manner,  is  peculiar. 

"In  a  fracture  of  the  clavicle  through  its  middle  third  (its  usual 
situation),  the  motion  is  upon  the  point  of  the  fracture  as  upon  a  pivot ; 
although,  therefore,  the  motion  is  almost  incessant,  it  does  not  essen- 
tially, if  at  all,  disturb  the  adhesive  process.  The  same  is  true  in 
nearly  all  other  fractures.  The  fragments  move  only  upon  themselves, 
and  not  to  and  from  each  other.  I  know  of  no  complete  exception 
but  in  the  case  now  under  consideration. 

"Aside  from  any  speculation,  the  facts  are  easily  verified  by  a  per- 
sonal examination  of  the  patients  during  the  first  or  second  week  of 
treatment,  or  at  any  time  before  union  has  occurred,  both  in  fractures 
of  the  humerus  and  clavicle.  The  latter  is  always  sufficiently  exposed 
to  permit  you  to  see  what  occurs;  and  as  soon  as  the  swelling  has  a 
little  subsided  in  the  former  case,  you  will  have  no  difficulty  in  feeling 
the  motion  outside  of  the  dressings,  or,  perhaps,  in  introducing  the 
finger  under  the  dressings  sufficiently  far  to  reach  the  point  of  fracture. 
I  believe  you  will  not  fail  to  recognize  the  difference  in  the  motion 
between  the  two  cases.  Such,  gentlemen,  is  the  explanation  which  I 
wish  to  offer  for  the  relative  frequency  of  this  very  serious  accident — 
non-union  of  the  humerus. 

"I  know  of  no  other  circumstance  or  condition  in  which  this  bone 
is  peculiar,  and  which,  therefore,  might  be  invoked  as  an  explanation. 
Overlapping  of  the  bones,  the  cause  assigned  by  some  writers,  is  not 
sufficient,  since  it  is  not  peculiar.  The  same  occurs  much  oftener, 
and  to  a  much  greater  extent,  in  fractures  of  the  femur,  and  equally 
as  often  in  fractures  of  the  clavicle,  yet  in  neither  case  are  these  results 
so  frequent.  Nor  can  it  be  due  to  the  action  of  the  deltoid  muscle,  or 
of  any  other  particular  muscles  about  the  arm,  whether  the  fracture 
be  below  or  above  their  insertions,  since  similar  muscles,  with  similar 
attachments,  on  the  femur  and  on  the  clavicle,  tending  always  power- 
fully to  the  separation  of  the  fragments,  occasion  deformity,  but  they 
seldom  prevent  union, 

"If  I  am  correct  in  my  views,  we  shall  be  able  sometimes  to  con- 
summate union  of  a  fractured  humerus  where  it  is  delayed,  by  straight- 
ening the  forearm  upon  the  arm,  and  confining  them  to  this  position. 
A  straight  splint,  extending  from  the  top  of  the  shoulder  to  the  hand, 
constructed  from  some  firm  material,  and  made  fast  with  rollers,  will 
secure  the  requisite  immobility  to  the  fracture.  Tiie  weight  of  the 
forearm  and  hand  will  only  tend  to  keep  the  fragments  in  place,  and 
if  the  splint  and  bandages  are  sufficiently  tight,  the  motion  occasioned 
by  swinging  the  hand  and  forearm  will  be  conveyed  almost  entirely 
to  the  shoulder-joint.  Very  little  motion,  indeed,  can  in  this  posture 
be  communicated  to  the  fragments,  and  what  little  is  thus  communi- 
cated is  a  motion,  as  experience  has  elsewhere  shown,  not  disturbing 
or  pernicious,  but  a  motion  only  upon  the  ends  of  the  fragments,  as 
upon  a  pivot. 

"I  do  not  fail  to  notice  that  this  position  has  serious  objections,  and 
that  it  is  liable  to  inconveniences  which  must  always,  probably,  pre- 
vent its  being  adopted  as  the  usual  plan  of  treatment  for  fractured 


214  FRACTURES    OF    THE    HUMERUS. 

arms.  It  is  more  inconvenient  to  get  up  and  lie  down,  or  even  to  sit 
down,  in  this  position  of  the  arm,  and  the  hand  is  liable  to  swell. 
But  I  shall  not  be  surprised  to  learn  that  experience  will  prove  these 
objections  to  have  less  weight  than  we  are  now  disposed  to  give  them. 
Eemember,  the  practice  is  yet  untried — if  I  except  the  case  which  I 
am  about  to  relate,  and  in  which  case,  I  am  free  to  say,  these  objec- 
tions scarcely  existed.  The  swelling  of  the  hand  was  trivial,  and  only 
continued  through  the  first  fortnight,  and  the  patient  never  spoke  of 
the  inconvenience  of  getting  up  or  sitting  down,  or  even  of  lying  down. 

"  The  following  is  the  case  to  which  I  have  just  referred  :  '  Michael 
Mahar,  laborer,  ».t.  35,  broke  his  left  humerus  just  below  its  middle, 
Dec.  14,  1853.  The  arm  was  dressed  by  a  surgeon  in  Canada  West, 
and  who  is  well  known  to  me  as  exceedingly  "clever."  After  a  few 
days  from  the  time  of  the  accident,  "the  starch  bandage  was  put  on 
as  tight  as  it  could  be  borne,  and  brought  down  on  the  forearm,  so 
as  to  confine  the  motions  of  the  elbow-joint."  Six  weeks  after  the 
injury,  Jan.  29,  1854,  Mahar  applied  to  me  at  the  hospital.  No  union 
had  occurred.  The  motion  between  the  fragments  was  very  free,  so 
that  they  passed  each  other  with  an  audible  click.  There  was  little 
or  no  swelling  or  soreness.  In  short,  everything  indicated  that  union 
was  not  likely  to  occur  without  operative  interference.  The  elbow 
was  completely  anchylosed.  I  explained  to  my  students  what  seemed 
to  me  to  be  the  cause  of  the  delayed  union,  and  declared  to  them  that 
I  did  not  intend  to  attempt  to  establish  adhesive  action  until  I  had 
straightened  the  arm.  They  had  just  witnessed  the  failure  of  a  pre- 
cisely similar  case,  in  which  I  had  made  the  attempt  to  bring  about 
union  without  previously  straightening  the  arm. 

"'On  the  6th  of  Feb.  1854,  we  had  succeeded  in  making  the  arm 
nearly  straight.  I  now  punctured  the  upper  end  of  the  lower  frag- 
ment with  a  small  steel  instrument,  and,  as  well  as  I  was  able,  thrust 
it  between  the  fragments.  Assisted  by  Dr.  Boardman,  I  then  applied 
a  gutta-percha  splint  from  the  top  of  the  shoulder  to  the  fingers, 
moulding  it  carefully  to  the  whole  of  the  back  and  sides  of  the  limb, 
and  securing  it  firmly  with  a  paste  roller.  March  4th  (not  quite  four 
weeks  after  the  application  of  the  splint)  we  opened  the  dressings  for 
the  second  time,  and  carefully  renewed  them.  A  slight  motion  was  yet 
perceptible  between  the  fragments.  March  18th,  we  opened  the  dress- 
ings for  the  third  time,  and  found  the  union  complete.  This  was 
within  less  than  forty  days.  The  patient  was  now  dismissed.  On  the 
29th  of  April  following,  the  bone  was  refractured.  Mahar  had  been 
assisting  to  load  the  "tender"  to  a  locomotive.  As  the  train  was  just 
getting  in  motion,  he  was  hanging  to  the  tender  by  his  sound  arm, 
while  another  laborer  seized  upon  his  broken  arm  to  keep  himself 
upon  the  car,  and  with  a  violent  and  sudden  pull  wrenched  him  from 
the  tender  and  reproduced  the  fracture.  The  next  morning  I  applied 
the  dressings  as  before,  and  did  not  remove  them  during  three  weeks; 
at  the  end  of  which  time  the  union  was  again  complete.  The  splint 
was,  however,  reapplied,  and  has  been  continued  to  this  time — a  period 
of  about  six  weeks.'  "^ 

'  Buffalo  Med.  Journ.,  vol.  x.  pp.  14-147. 


BASE    OF    THE    CONDYLES.  245 

Since  the  date  of  the  above  paper,  I  have  three  times  had  oppor- 
tunities to  test  the  value  of  this  mode  of  treatment  in  cases  of  delayed 
union  of  the  humerus,  and  in  each  case  with  the  same  favorable  result. 

§  6.  Base  of  the  Condyles.     Syn.   Supracondyloid  Fracture  of  the  Hu- 
merus.— Malgaigne. 

Causes. — Of  sixteen  fractures  at  this  point,  ten  occurred  in  children 
under  ten  years  of  age,  the  youngest  being  two  years  old. 

In  ten  cases  the  fracture  had  been  produced  by  a  fall,  and  it  is 
presumed  that  the  blow  was  received  upon  the  elbow;  in  the  remain- 
ing six  cases  the  cause  is  not  stated.  I  believe,  therefore,  that  this 
fracture  is  generally  the  result  of  an  indirect  blow,  inflicted  upon  the 
extremity  of  the  elbow ;  in  a  few  examples  it  has  been  produced  by 
a  blow  received  directly  upon  the  point  of  fracture,  as  by  the  kick  of 
a  horse,  &c.,  but  I  have  never,  save  in  a  single  instance,  been  able  to 
trace  it  to  a  fall  upon  the  hand.  Dr.  Shearer,  U.  S.  A.,  has  reported 
a  case  also,  which  seems  to  have  occurred  in  the  same  manner.^ 

Fisr.  70. 


Fractures  at  the  base  of  the  condyles.    (From  Gray.) 

Direction  of  the  Fracture,  Displacement,  and  Symptoms. — I  think 
this  fracture  is  generally  oblique,  and  its  line  of  direction  upwards 
and  backwards;  in  nine  of  the  eleven  cases  where  this  point  was 
determined,  such  has  been  its  apparent  direction,  and  the  lower  frag- 
ment has  been  found  drawn  up  behind  the  upper.  Once  I  have  found 
the  lower  fragment  in  front,  and  once  on  the  outside  of  the  upper. 

Three  of  the  sixteen  were  compound  comminuted  fractures,  this 
being  a  larger  proportion  of  serious  complications  than  is  usually 
found  in  connection  with  fractures  of  long  bones. 

I  have  never  met  with  what  I  supposed  to  be  a  separation  of  the 
lower  epiphysis,  but  surgical  writers  have  occasionally  spoken  of  this 
accident,  and  Dr.  Watson,  of  New  York,  believes  that  he  has  seen  one 
example  in  an  infant  not  quite  two  years  old.  The  limb  had  been 
violently  wrenched  by  the  mother,  in  attempting  to  lift  her.  She  was 
not  seen  by  Dr.  Watson  until  the  fourth  day,  at  which  time  the  svvell- 

'  M.  M.  Shearer,  Act.  Asst.  Surgeon  U.  S.  A.  Boston  Jouru.  of  Chemistry, 
Feb.  1,  1870. 


246 


FRACTUKES    OF    THE    HUMERUS. 


Fiff.  71. 


ing  was  sucb  that  the  diagnosis  could  not  be  easily  made  out;  but  on 
the  ninth  day  "  it  was  apparent  that  the  shaft  of  the  humerus  had  been 
separated  from  its  cartilaginous  expansion  at  the  condyles,  near  the 
elbow."  By  the  use  of  angular  pasteboard  splints,  the  reduction  was 
maintained,  and  the  fragments  became  united  after  about  four  or  six 
weeks,' 

Dr.  J.  C.  Reeve,  of  Dayton,  Ohio,  has  recently  sent  me  a  specimen 
of  this  fracture  which  occurred  in  his  practice  in  the  year  1864:.  A 
girl,  set.  10,  fell  a  few  feet,  striking,  probably,  upon  her 
elbow.  The  fracture  was  compound,  and  union  not  hav- 
ing occurred  at  the  end  of  three  weeks,  the  condition 
of  the  arm  rendered  amputation  necessary.  In  this  case 
a  small  fragment  of  the  shaft  came  away  with  the  epi- 
physis. Drs.  Little,  Voss,  and  Buck,  of  this  city,  have 
each  reported  a  similar  case.^ 

The  diagnosis  of  this  fracture  is  attended  with  pecu- 
liar difficulties,  and  it  has  occasionally  been  mistaken 
for  a  dislocation  of  the  radius  and  ulna  backwards. 
Dupuytren  says:  "There  is  nothing  so  common  as  to 
see  a  fracture  of  the  lower  end  of  the  humerus,  imme- 
diately above  the  elbow-joint,  mistaken  for  a  dislocation 
backward;"  and  he  m.entions  three  cases  which  have 
come  under  his  own  observation.  I  have  found  an  op- 
posite error,  however,  by  far  the  most  frequent,  namely, 
a  dislocation  of  both  bones  backwards  has  been  sup- 
posed to  be  a  fracture. 

The  sources  of  this  embarrassment  are  found  in  the 
proximity  of  the  fracture  to  the  joint,  in  the  rapidity 
with  which  swelling  occurs,  and  in  the  striking  simi- 
larity of  the  symptoms  which  characterize  the  two  acci- 
dents. 
It  will  be  necessary,  therefore,  to  establish  with  care 
the  differential  diagnosis.     The  following  are  the  signs  of  fracture: — 

1.  Preternatural  mobility,  which,  owing  to  the  rapidity  of  the  swell- 
ing and  the  contraction  of  the  muscles  whose  tendons  are  stretched 
over  the  projecting  ends  of  the  bones,  is  often  soon  lost,  being  suc- 
ceeded, sometimes  after  a  few  hours,  by  a  rigidity  equal  to  that  which 
is  usually  present  in  dislocations,  or  even  greater.  It  is  especially 
difficult  to  flex  the  arm,  owing  to  the  pressure  by  the  upper  fragment 
into  the  bend  of  the  elbow. 

2.  Crepitus.  This  can  usually  be  detected  at  any  period  if  the  arm 
is  sufficiently  extended,  so  as  to  bring  the  broken  surfaces  again  into 
apposition. 

3.  When  the  extension  is  sufficient,  reduction  is  easily  effected,  and 
the  natural  length  of  the  arm  is  restored;  but  the  limb  immediately 
shortens  when  the  extension  is  discontinued — especially  if  at  the 
same  moment  the  elbow  is  bent.  This  is  a  very  important  means  of 
diagnosis. 


Separation    of 
lower  epiphysis. 


'  Watson,  New  York  Joum.  Med.,  Nov.  1853,  p.  430,  second  series,  vol.  xi. 
'^  Little,  Voss,  and  Buck,  New  York  Jouru.  Med.,  Nov.  1865,  p.  133. 


'BASE    OF    THE    CONDYLES.  247 

4.  A  careful  measurement,  made  from  the  point  of  the  internal  con- 
dyle to  the  acromion  process,  declares  a  positive  shortening  of  the 
humerus. 

5.  By  flexing  and  extending  the  forearm  upon  the  arm,  while  the 
fingers  are  placed  upon  the  lower  portion  of  the  humerus,  the  project- 
ing fragments  can  be  felt.  Generally,  the  upper  fragment  being  in 
front  of  the  lower,  and  pressing  down  into  the  bend  of  the  elbow,  its 
end  cannot  be  so  easily  recognized;  but  the  upper  end  of  the  lower 
fragment  can  easily  be  made  out  when  the  forearm  is  considerably 
flexed.  The  lower  end  of  the  upper  fragment  feels  more  rough,  and 
is  less  wide,  than  in  dislocations. 

6.  The  whole  of  the  lower  fragment  is  carried  backwards,  and  with 
it  the  radius  and  ulna,  producing  a  striking  prominence  of  the  elbow 
and  olecranon  process.  Efforts  to  straighten  the  forearm  upon  the 
arm,  when  no  extension  is  used,  increase  rather  than  diminish  this 
projection. 

7.  The  forearm  is  slightly  flexed  upon  the  arm,  the  angle  made  at- 
the  elbow  being  about  25  or  30  deg. 

8.  The  hand  and  forearm  are  pronated. 

9.  The  relations  of  the  olecranon  process  with  the  two  condyles 
remain  unchanged. 

In  a  case  of  epiphyseal  separation,  the  lower  end  of  the  upper  frag- 
ment has  greater  breadth  than  in  the  case  of  a  fracture  at  the  base  of 
the  condyle,  and  the  line  of  separation  is  nearer  the  end  of  the  bone. 

Signs  of  a  dislocation  of  the  radius  and  ulna  backwards. 

1.  Preternatural  immobility.  That  is  to  say,  extension  and  flexion 
are  limited,  but  there  is  almost  always  present  a  preternatural  lateral 
mobility. 

2.  Absence  of  crepitus.  It  is  in  this  joint  especially  that  surgeons 
have  been  deceived  by  the  chafing  of  the  dislocated  bones  upon  the 
inflamed  joint  surfaces,  and  have  supposed  that  they  discovered  crepi- 
tus when  no  fracture  existed.  The  rapidity  with  which  inflammation 
develops  itself  after  dislocations  of  the  elbow-joint,  and  the  consequent 
abundant  efi'usion  of  lymph,  afford  the  probable  explanation  of  this 
frequent  error. 

3.  When  reduced,  the  bones  are  not  generally  disposed  to  become 
again  displaced,  even  though  the  elbow  should  be  flexed. 

4.  The  humerus  is  not  shortened,  but  the  olecranon  process  ap- 
proaches the  acromion  process. 

5.  There  are  no  sharp  projecting  points  of  bone.  The  lower  end 
of  the  humerus  may  not  always  be  felt  in  the  bend  of  the  elbow;  but 
when  it  is  felt,  it  is  found  to  be  relatively  smooth,  broad,  and  round. 

6.  A  remarkable  prominence  of  the  elbow  and  olecranon  process, 
which  prominence  is  sensibly  diminished  when  an  effort  is  made  to 
straighten  the  forearm  on  the  arm. 

7.  Forearm  flexed  upon  the  arm  to  about  the  same  degree  as  in 
fracture. 

8.  Hand  and  forearm  pronated,  precisely  as  in  fracture. 

9.  Kelations  of  the  olecranon  process  to  the  condyles  changed  very 
greatly. 


248  FEACTURES    OF    THE    HUMERUS. 

The  most  constant  diagnostic  signs  are,  then,  in  the  case  of  a  frac- 
ture, crepitus,  shortening  of  the  humerus,  projection  of  the  sharp 
ends  of  the  fragments,  and  an  increase  of  the  projection  of  the  elbow 
when  an  attempt  is  made  to  straighten  the  arm;  and  in  the  case  of  a 
dislocation,  the  absence  of  crepitus,  humerus  not  shortened,  while  the 
olecranon  approaches  the  acromion  process;  the  smooth,  round  head 
of  the  humerus  lost,  or  indistinctly  felt  in  the  bend  of  the  elbow,  and 
the  projection  of  the  point  of  the  elbow  diminished  when  an  attempt 
is  made  to  straighten  the  forearm  on  the  arm. 

It  is  proper,  also,  to  repeat  here  what  we  have  already  said  in  rela- 
tion to  the  causes  of  this  fracture.  A  fracture  at  this  point  is  pro- 
duced almost  always  by  a  fall  upon  the  elbow,  but  a  dislocation  of  the 
radius  and  ulna  backwards  can  never  be.  On  the  other  hand,  a  dislo- 
cation is  produced,  in  most  cases,  by  a  fall  upon  the  palm  of  the  hand, 
while  I  have  never  known  but  one  fracture  above  the  condyles  to  be 
thus  produced. 

Besults. — Nine  times  have  I  found  the  arm  shortened  from  half  an 
inch  to  one  inch,  or  a  little  more. 

Muscular  anchylosis  is  almost  always  present  when  the  apparatus 
is  first  removed,  and  it  is  seldom  completely  dissipated  until  after 
several  months;  but  I  have  found  m.ore  or  less  anchylosis  at  seven 
and  nine  months  ;  and  twice  after  the  lapse  of  three  years  the  motions 
of  the  joint  have  been  very  limited.  A  few  years  since,  I  examined 
the  arm  of  a  gentleman  who  was  then  twenty-seven  years  old,  and 
who  informed  me  that  when  he  was  four  years  old  he  broke  the 
humerus  just  above  the  condyles.  There  still  remained  a  sensible 
deformity  at  the  point  of  fracture — he  could  not  completely  supine 
the  forearm.  The  whole  arm  was  weak,  and  the  ulnar  nerve  re- 
markably sensitive.  The  ulnar  side  of  the  forearm,  and  also  the  ring 
and  little  fingers,  were  numb,  and  have  been  in  this  condition  ever 
since  the  accident.  I  know  the  surgeon  very  well  who  had  charge  of 
this  case,  and  I  have  no  doubt  that  the  treatment  was  carefully  and 
skilfully  applied. 

In  June  of  1850,  I  operated  upon  a  lad,  nine  years  old,  by  sawing 
off  the  projecting  end  of  the  upper  fragment,  whose  arm  had  been 
broken  nine  months  before.  This  fragment  was  lying  in  front  of  the 
lower,  and  the  skin  covering  its  sharp  point  was  very  thin  and  tender. 
There  was  no  anchylosis  at  the  elbow-joint,  but  the  hand  was  flexed 
forcibly  upon  the  wrist,  the  first  phalanges  of  all  the  fingers  ex- 
tended, and  the  second  and  third  flexed.  Supination  and  pronation 
of  the  forearm  were  lost.  The  forearm  and  hand  were  almost  com- 
pletely paralyzed,  but  very  painful  at  times.  The  ulnar  nerve  could 
be  felt  lying  across  the  end  of  the  bone. 

In  the  hope  that  some  favorable  change  might  result  to  the  hand 
by  relieving  the  pressure  upon  the  nerve,  yet  with  not  much  expecta- 
tion of  success,  I  exposed  the  bone  and  removed  the  projecting  frag- 
ment. The  nerve  had  to  be  lifted  and  laid  aside.  About  one  year 
from  this  time  I  found  the  arm  in  the  same  condition  as  before  the 
operation. 

Non-union  is  a  result  not  so  frequent  in  fractures  at  this  point  as 


BASE    OF    THE    CONDYLES. 


249 


higher  up  ;  but  Stephen  Smith,  of  the  Bellevue  Hospital,  New  York, 
reports  a  case  of  nou-uuion  in  a  young  man  of  twenty-three  years.  He 
was  admitted  to  the  hospital  on  the  seventh  day  after  the  accident. 
The  fracture  was  simple  and  transverse,  yet  at  the  end  of  four  months 
he  was  dismissed  "  with  perfectly  free  motion  at  the  point  of  fracture."^ 
The  failure  to  unite  was  attributed  to  a  syphilitic  taint. 

A  case  was  tried  a  few  years  since  in  the  Supreme  Court  at  Brook- 
lyn, N.  Y.,  in  which,  after  a  simple  fracture  at  this  point,  the  arm 
being  dressed  with  splints  and  bandages,  the  little  finger  sloughed  oft' 
in  a  condition  of  dry  gangrene,  and  the  adjacent  parts  of  the  hand 
were  attacked  with  humid  mortification.  Drs.  Parker  and  Prince 
believed  that  this  serious  accident  was  the  result  of  bandages  applied 
too  tightly  and  suffered  to  remain  too  long,  while  Drs.  Valentine  Mott, 
Rogers,  Wood,  Ay  res,  Dixon,  and  others,  believed  the  gangrene  might 
have  been  due  to  other  causes  over  which  the  surgeon  had  no  control.^ 
A  few  years  ago,  a  similar  case  occurred  in  the  town  of  Spencer, 
Tioga  Co.,  N.  Y. ;  a  boy,  six  years  old,  having  broken  his  humerus 
just  above  the  condyles.  The  fracture  was  oblique.  The  surgeon 
who  was  called  to  treat  the  case  was  an  old  and  highly  respectable 
practitioner.  I  am  not  informed  of  the  plan  of  treatment  any  farther 
than  that  a  roller  was  applied.  On  the  eighth  day,  a  second  surgeon 
was  employed,  who,  finding  the  hand  cold  and  insensible,  removed  all 
of  the  dressings;  after  which  the  thumb  and  forefinger  sloughed,  with 
other  portions  of  the  skin  and  flesh  of  the  hand  and  arm.  The  sur- 
geon who  was  first  in  attendance  was  prosecuted,  and  the  case  was 
tried  in  the  Supreme  Court  of  that  county,  but  the  jury  found  no 
cause  of  action.  Dr.  Hawley,  of  Ithaca,  and  the  late  Dr.  Webster,  of 
Geneva  Medical  College,  testified  that,  in  their  opinion,  the  death  of 
the  fingers  was  owing  to  the  pressure  of  the  fragment  upon  the  bra- 
chial artery,  and  not  to  the  tightness  of  the  bandages. 

Dr.  Gross  has  also  informed  us  of  still  another  case  of  the  same 
character,  which  occurred  in  Warren  Co.,  Ky.  A  boy,  ten  years  old, 
had  broken  his  arm  above  the  condyles,  and  his  parents  having  em- 
ployed a  surgeon  residing  at  some  distance,  the  dressings  were  applied, 

and  directions  given  to  send  for 
the  surgeon  whenever  it  became 
necessary.  The  parents  saw  the 
arm  swell  excessively,  and  knew 
that  the  boy  was  suffering  very 
much,  but  did  not  notify  the 
surgeon  until  the  tenth  day, 
when  the  hand  was  found  to  be 
in  a  condition  of  mortification, 
and  at  length  amputation  became 
necessary. 

Long   afterward,    in   the  year 
Physick's  elbow  splints.  l^ol,  whcu  the  boy  became  of 

'  Smith,  New  York  Journal  of  Medicine,  May,  1857,  p.  386,  third  series,  vol.  ii. 
2  New  York  Medical  Gazette,  vol.  xii.  pp.  46,  80,  111. 

17 


Fis.  73. 


250 


FKACTUEES    OF    THE    HUMERUS. 


age,  he  prosecuted  his  surgeon,  but  with  no  result  to  either  party 
beyond  the  payment  of  their  respective  costs. 

While  I  would  not  deny  that  in  all  of  these  cases  the  sloughing  might' 
have  been  solely  due  to  the  tightness  of  the  bandages,  against  which 
cruel  and  mischievous  practice  we  cannot  too  loudly  declaim,  a  know- 
ledge of  the  anatomy  of  these  parts,  and  the  opinions  of  the  very  dis- 

ri"r.  73. 


Kirkbride's  elbow  splint. 


tinguished  gentlemen  who  testified  in  defence  of  these  surgeons,  must 
compel  us  to  admit  the  possibility  of  such  accidents  where  the  treat- 
ment has  been  skilful  and  faultless. 


Fig.  74. 


Fiff.  75. 


Welch's  splint.     The  hinges  may  be  transferred  to 
splints  of  different  sizes. 

Treatment. — The  splints  generally  employed  in- this  country,  in  frac- 
tures about  the  elbow-joint,  are  simple  angular  side  splints,  without 
joints,  such  as  those  recommended  by  Physick:^  angular  pasteboard 

'  Elemeuts  of  Surgery,  by  John   Syng  Dorsey,  Philadelphia  edition,   vol.  i. 
p.  145. 


BASE    OF    THE    CONDYLES. 


251 


splints,  felt,  leather,  gutta  percha,  &c.,  or  angular  splints  with  a 
hinge,  such  as  Kirkbride's,'  Thomas  Hewson's  Day's,  or  Rose's,  or 
the  more  perfect  and  elegant  angular  splint  of  Welch. 

Kirkbride's  splint,  which  has  been  used  in  the  Pennsylvania  Hos- 
pital in  several  instances,  is  composed  of  two  pieces  of  board,  connected 
together  by  a  circular  joint,  and  having  eyes  on  the  inner  edge,  two 
inches  apart,  and  holes  through  the  splint  at  graduated  distances 
between  them.  There  is  also  a  swivel  eye,  passing  through  the  upper 
part  of  the  splint,  and  riveted  below.  A  wire  is  fastened  to  the  swivel, 
and  bent  at  right  angles  at  its  other  extremity,  of  a  size  to  fit  the  eyes 
and  holes  in  the  splint.  This  splint,  properly  supported  by  pads,  is 
to  be  placed  either  upon  the  outside  or  inside  of  the  arm,  and  secured 
by  rollers.  When  the  angle  is  to  be  changed,  the  wire  is  unhooked 
and  removed  to  another  eye,  or  to  some  of  the  intermediate  holes  upon 
the  side  of  the  splint.  Dr.  Kirkbride  reports  two  cases  of  fracture  of 
the  lower  part  of  the  humerus  treated  by  this  plan,  one  of  which 
resulted  in  anchylosis,  but  the  other  was  much  more  successful. 

H.  Bond,  of  Philadelphia,  has  contrived  a  very  ingenious  splint  for 
the  elbow-joint,  and  which  is  designed  also  to  afford  a  complete  sup- 
port to  the  forearm. 

Por  myself,  I  generally  prefer  gutta  percha,  moulded  and  applied 
accurately  to  the  limb.     It  should  be  extended  beyond  the  elbow  to 

Fis.  76. 


Bond's  elbow  splint. 

the  wrist,  so  as  to  support  the  whole  length  of  the  arm,  elbow,  and 
forearm.  Some  experience  in  the  use  of  wooden  angular  splints  has 
convinced  me  that  they  cannot  be  very  well  fitted  to  the  many  in- 
equalities of  the  limb ;  and  neither  pasteboard  nor  binder's  board  has 
sufficient  firmness,  especially  in  that  portion  which  covers  the  joint. 
Angular  splints,  furnished  with  a  movable  joint,  possess  the  advantage 
of  enabling  us  to  change  the  angle  of  the  limb  at  pleasure,  and  of  keep- 
ing up  some  degree  of  motion  in  the  articulation  without  disturbing 
the  fracture  or  removing  the  dressings ;  but  the  cross-bars  of  Day's  and 

'  American  Journal  of  the  Medical  Sciences,  vol.  xvi.  p.  315. 


252 


FRACTUKES    OF    THE    HUMERUS. 


Eose's  splints  render  tliem  complicated,  and  are  in  the  way  of  a  nice  ap- 
plication of  the  rollers ;  while  they  are  all  equally  liable  to  the  objec- 
tion stated  against  angular  wooden  splints  without  joints,  viz.,  that  they 
seldom  can  be  made  to  fit  accurately  the  many  irregularities  of  the 
arm,  elbow,  and  forearm.  In  applying  the  author's  splint,  care  must 
be  taken  that  the  humeral  portion  is  not  too  short,  or  the  result  will 
be  an  unnecessary  degree  of  overlapping  of  the  fragments.     This  may 

generally  be  avoided  if  the  sur- 
Fig.  77.  geon  will  first  shape  his  material 

to  the  sound  arm,  while  the  whole 
length  is  underlaid  with  three  or 
four  thicknesses  of  woollen  cloth. 
Welch's  splints,  made  of  a  mate- 
rial possessing  a  slight  amount  of 
flexibility,  approach  more  nearly 
the  accomplishment  of  these  indi- 
cations than  any  other  manufac- 
tured splint  with  which  I  am 
acquainted,  but  the  number  of 
cases  in  practice  to  which  they 
are  applicable  will  be  found  to 
be  limited,  while  gutta  percha 
has  no  limit  in  its  application. 

Whatever  material  is  employed, 
the  splint  should  be  first  lined 
with  one  thickness  of  woollen 
cloth,  or  some  proper  substitute. 
A  pretty  large  pledget  of  fine 
cotton  batting  ought  also  to  be 
laid  in  front  of  the  elbow-joint,  to 
prevent  the  roller  from  exco- 
riating the  delicate  and  inflamed  skin  ;  and  great  care  should  be  taken 
to  protect  the  bony  eminences  about  the  joint,  or,  rather,  to  relieve 
them  from  pressure,  by  increasing  the  thickness  of  the  pads  above 
and  below  these  eminences. 

At  a  very  early  day,  so  early,  indeed,  as  the  seventh  or  eighth  day, 
the  splint  should  be  removed,  and,  while  the  fragments  are  steadied, 
gentle,  passive  motion  should  be  inflicted  upon  the  joint.  This  prac- 
tice should  be  repeated  as  often  as  every  second  or  third  day,  in  order 
to  prevent,  as  far  as  possible,  anchylosis.  If  much  swelling  follows 
the  injury,  it  is  my  custom  to  open  the  dressings,  without  rernoving 
the  splints,  on  the  second  or  third  day  after  the  accident,  or  at  any 
time  when  the  symptoms  admonish  of  its  necessity.  Occasionally 
it  is  well  to  change  the  angle  of  the  splint  before  reapplying  it.  If 
the  angular  splint  with  a  movable  joint  is  used,  slight  changes  may  be 
made  while  the  splint  is  on  the  arm  ;  but  if  the  angle  is  much  changed 
without  removing  the  rollers,  they  become  unequally  tightened  over 
the  arm,  and  may  do  mischief 

When  anchylosis  has  actually  taken  place,  we  may  more  or  less 


The  author 


TRACTURE  AT  THE  BASE  OF  THE  CONDYLES. 


253 


overcome  the  contraction  of  the  muscles  and  of  the  ligaments  by  pas- 
sive motion,  or  by  directing  the  patient  to  tfvving  a  dumb  bell  or  some 
other  heavy  weight,  as  first  recommended  by  Hildanus. 


Fracture  at  the  base  of,  and 
between,  the  condyles. 


§  T.  Fracture  at  the  Base  op  the  Condyles,  complicatet)  with  Frac- 
ture BETWEEN  THE  CONDYLES,  EXTENDING  INTO  THE  JoiNT. 

This  fracture,  which  is  but  a  variety  or  complication  of  the  preced- 
ing, is  even  more  difficult  of  diagnosis ;  and  its  signs,  results,  and 
proper  treatment  differ  sufficiently  to  demand 
a  separate  consideration. 

I  have  recognized  the  accident  six  times. 
Confined  to  no  period  of  life,  it  seems  to  be  the 
result  of  a  severe  blow  inflicted  directly  upon 
the  lower  and  back  part  of  the  humerus,  or 
upon  the  olecranon  process.  Dr.  Parker,  of 
New  York,  was  inclined  to  regard  an  obscure 
accident  about  the  elbow-joint,  which  he  saw 
in  a  lad  sixteen  years  -old,  as  a  longitudinal 
fracture  of  the  humerus,  with  separation  of  one 
condyle,  but  which  had  been  occasioned  by  a 
fall  upon  the  hand.^  For  myself,  I  should  re- 
gard this  latter  circumstance  as  presumptive 
evidence  that  it  was  not  a  fracture  of  this  cha- 
racter, yet  I  do  not  mean  to  deny  the  possibility  of  its  occurrence  in 
this  way. 

Its  characteristic  symptoms  are,  increased  breadth  of  the  lower  end 
of  the  humerus,  occasioned  by  a  separation  of  the  condyles;  displace- 
ment upwards  and  backwards  of  the  radius  and  ulna;  crepitus  and 
mobility  at  the  base  of  the  condyles,  with  crepitus  also  between  the 
condyles,  developed  by  pressing  them  together ;  or  when  the  radius 
and  ulna  are  drawn  up,  by  restoring  these  bones  first  to  place  by 
extension,  and  then  pressing  upon  the  opposite  condyles ;  shortening 
of  the  humerus. 

Its  consequences  are,  generally,  great  inflammation  about  the  joint, 
permanent  deformity  and  bony  anchylosis.  An  opposite  result  must 
be  regarded  as  fortunate,  and  as  an  exception  to  the  rule. 

Of  the  treatment  we  can  only  say  that  it  must  be  chiefly  directed 
to  the  prevention  and  reduction  of  inflammation,  at  least  during  the 
first  few  days.  Nor  is  this  inconsistent  with  an  early  reduction  of  the 
fragments,  and  moderate  efforts,  by  splints  and  bandages,  such  as  we 
have  directed  in  case  of  a  simple  fracture  at  the  base  of  the  condyles, 
to  keep  the  fragments  in  place.  No  surgeon  would  be  justified  in 
refusing  altogether  to  make  suitable  attempts  to  accomplish  these  im- 
portant indications;  but  he  must  always  regard  them  as  secondary 
when  compared  with  the  importance  of  controlling  the  inflammation. 

When  splints  are  employed,  the  same  rules  will  be  applicable,  both 
as  to  their  form  and  mode  of  application,  as  in  cases  of  simple  fracture 
above  the  condyles. 


'  Parker,  New  York  Journal  of  Medicine,  Nov.  1856,  p.  391,  3cl  series,  vol.  i. 


254  FKACTURES    OF    THE    HUMEEUS. 

The  following  examples  will  more  completely  illustrate  the  charac- 
ter, history,  and  proper  treatment  of  these  cases  than  any  remarks  or 
rules  which  we  can  at  present  make. 

A  woman,  get.  44,  fell  upon  the  side-walk  in  January,  1850,  striking 
upon  her  right  elbow,  I  saw  her  a  few  minutes  after  the  accident, 
but  the  parts  about  the  joint  were  already  considerably  swollen,  and 
it  was  not  without  difficulty  that  the  diagnosis  was  made  out.  The 
forearm  was  slightly  flexed  upon  the  arm,  and  pronated.  On  seizing 
the  elbow  firmly,  a  distinct  motion  was  perceived  above  the  condyles, 
and  a  crepitus.  I  could  also  feel,  indistinctly,  the  point  of  the  upper 
fragment.  While  moderate  extension  was  made  upon  the  arm,  the 
condyles  were  pressed  together,  when  it  was  apparent  that  they  had 
been  separated.  On  removing  the  extension,  they  again  separated, 
and  the  olecranon  drew  up.  She  was  in  a  condition  of  extreme  ex- 
haustion, and  the  bones  were  easily  placed  in  position. 

An  angular  splint  was  secured  to  the  limb,  and  every  care  used  to 
support  the  fragments  completely,  but  gently. 

From  this  date  until  the  conclusion  of  the  treatment  the  dressings 
were  removed  often,  and  the  elbow  moved  as  much  as  it  was  possible 
to  move  it. 

Seven  months  after  the  accident,  the  elbow  was  almost  completely 
anchylosed  at  a  right  angle.  The  fingers  and  wrist  also  were  quite 
rigid.  Six  years  later,  the  anchylosis  had  nearly  disappeared  ;  she 
could  now  flex  and  extend  the  arm  almost  as  much  as  the  other ;  the 
wrist-joint  was  free,  and  the  fingers  could  be  flexed,  but  not  sufficiently 
to  touch  the  palm  of  the  hand.  The  line  of  fracture  through  the  base 
could  be  traced  easily,  but  the  humerus  was  not  shortened.  There 
was,  moreover,  much  tenderness  over  the  point  of  fracture  through  the 
base,  and  at  other  points.  Occasionally,  a  slight  grating  was  noticed 
in  the  radio-humeral  articulation.  She  experienced  frequent  pains  in 
the  arm,  and  especially  along  the  back  and  radial  border  of  the  ring 
finger.  During  the  first  year  or  two  after  the  accident,  the  arm  per- 
ished very  much,  but  although  the  hand  remained  weak,  the  muscles 
were  now  well  developed. 

A  gentleman  was  struck  with  the  tongue  of  a  carriage  v/ith  which 
a  couple  of  horses  were  running.  The  blow  was  received  directly 
upon  the  back  of  the  left  elbow.  Dr.  Sprague  and  myself  removed 
some  small  fragments  of  bone,  and  while  opening  the  wound  for  this 
purpose,  we  could  see  distinctly  the  line  of  fracture  extending  into  the 
joint  as  well  as  across  the  bone.     The  condyles  were  not  separated. 

The  subsequent  treatment  consisted  only  in  the  use  of  such  means 
as  would  best  support  the  limb,  and  most  successfully  combat  inflam- 
mation. The  arm  and  forearm  were  laid  upon  a  broad  and  well- 
cushioned  angular  splint,  covered  with  oil-cloth,  to  which  they  were 
fastened  by  a  few  light  turns  of  a  roller. 

Twelve  years  after,  I  found  the  humerus  shortened  one  inch  and  a 
half.  During  the  first  year,  he  says,  there  was  no  motion  in  the  elbow- 
joint,  but  he  can  now  flex  and  extend  the  forearm  through  about  45° ; 
when  flexed  to  a  right  angle,  it  seems  to  strike  a  solid  body  like  bone. 
Kotation  of  the  forearm  is  completely  lost,  the  hand  being  in  a  posi- 


FEACTURE  AT  THE  BASE  OF  THE  CONDYLES.    255 

tion  midway  between  supination  and  pronation.  He  suffers  no  pain, 
and  his  arm  is  quite  strong  and  useful.  No  means  have  been  em- 
ployed to  restore  the  functions  of  the  limb  but  passive  motion  at  first. 
and  subsequently  constant,  active  use  of  the  hand  and  arm. 

The  late  Dr.  Thomas  Spencer,  of  Geneva,  used  to  relate  a  case  in 
which  a  surgeon  was  called  to  what  he  supposed  to  be  a  fracture  of  the 
lower  end  of  the  humerus,  and  which  he  treated  accordingly,  with 
splints,  &c.  On  the  second  or  third  day,  another  surgeon  was  called, 
who  removed  the  splints  and  bandages,  and  pronounced  it  a  disloca- 
tion of  the  radius  and  ulna  backward  ;  but  he  was  unable  to  reduce  it. 

After  some  time,  the  first  surgeon  was  prosecuted  for  having  treated 
as  a  fracture  what  proved  to  be  a  dislocation.  Dr.  Spencer,  who  had 
examined  the  arm  carefully,  gave  his  testimony  last,  and  at  a  time 
when,  from  the  evidence,  it  seemed  almost  certain  that  the  surgeon 
must  be  mulcted  in  heavy  damages ;  but  he  declared  his  belief  that 
both  surgeons  were  right,  since,  on  measuring  the  breadth  of  the 
humerus  through  its  two  condyles,  he  found  that  the  humerus  of  the 
injured  arm  was  three-quarters  of  an  inch  wider  than  the  opposite. 
His  conclusion,  therefore,  was  that  the  condyles  had  been  split  asunder 
and  were  now  separated ;  that  the  first  surgeon  properly  reduced  this 
fracture,  but  that  when,  on  the  second  or  third  day,  the  second  sur- 
geon removed  the  splints  and  the  dressings,  a  contraction  of  the  mus- 
cles had  taken  place  and  the  dislocation  occurred,  the  bones  of  the 
forearm  being  drawn  up  between  the  fragments.  Dr.  Spencer  believed 
this  was  an  example  of  the  variety  of  fractures  now  under  considera- 
tion, but  it  is  not  quite  certain  that  there  was  anything  more  than  an 
oblique  fracture  extending  into  the  joint,  followed  by  a  dislocation. 
In  either  case,  the  first  surgeon  was  entitled  to  an  acquittal,  and  so  the 
jury  promptly  declared  by  their  verdict. 

In  a  case  of  compound  comminuted  fracture  of  the  character  now 
under  consideration.  Dr.  Stone,  of  the  Bellevue  Hospital,  New  York, 
removed  the  condyles  and  sawed  off  the  sharp  end  of  the  humerus. 
The  woman  was  twenty-six  years  old  and  intemperate.  The  opera- 
tion was  made  as  a  substitute  for  amputation.  No  serious  complications 
followed.  On  the  ninety-sixth  day  the  wounds  were  completely  healed, 
and  she  could  bend  the  forearm  to  a  right  angle  with  the  arm,  the 
action  of  the  muscles  having  drawn  up  the  radius  and  ulna  against 
the  lower  end  of  the  shaft  of  the  humerus,  so  that  the  motions  were 
natural  and  free.^  The  practice,  as  the  result  sufficiently  shows,  was 
eminently  judicious ;  and  its  practicability  ought  always  to  be  well 
considered  before  resorting  to  the  serious  mutilation  of  amputation. 
The  great  principle  upon  which  the  success  of  resection  is  here  based 
is  the  shortening  of  the  bone,  whereby  the  reduction  may  be  accom- 
plished without  painful  tension  to  the  muscles ;  a  principle  which  will 
demand  of  us  hereafter  a  more  careful  consideration  and  a  wider 
application. 

'  Stone,  New  York  Jonrn.  of  Med.,  May,  1851,  p.  302,  vol.  vi.  3d  series. 


256 


FRACTUKES    OF    THE    HUMERUS, 


Fractures  of  the  Condyles. 

Chaussier  described  that  portion  of  the  lower  end  of  the  humerus 
which  articulates  with  the  ulna  as  the  trochlea,  and  that  portion  which 
articulates  with  the  radius  as  the  condyle ;  naming  the  two  lateral  pro- 
jections, respectively,  epitrochlea  and  epicondyle.  Some  of  the  French 
writers  have  adopted  this  nomenclature,  but  I  prefer,  as  being  more 
familiar  to  my  own  countrymen,  the  terms  external  and  internal  con- 
dyle, to  which  it  will  be  convenient  to  add  the  terms  external  epicon- 
dyle and  internal  epicondyle,  as  indicating  the  extreme  lateral  projec- 
tions, which  are  formed  from  separate  points  of  ossification,  and  which 
do  not  become  united  to  the  condyles  by  bone  until  about  the  sixteenth 
or  eighteenth  year  of  life. 

When,  therefore,  we  speak  of  a  fracture  of  the  epicondyle,  we  refer 
only  to  a  separation  of  the  epiphysis,  such  as  it  is  in  early  life;  or  to 
its  true  fracture,  when,  at  a  later  period,  it  has  become  united  by  bone. 


Fig.  79. 


§  8.  Fractures  of  the  Internal  Epicondyle.    {Epitrochlea,  Chaussier.) 

This  is  the  fracture  which  Granger  first  described  in  the  Edinburgh 
Medical  and  Surgical  Journal,^  and  which  he  ascribed  solely  to  muscu- 
lar action,  "  A  distinguishing  circumstance  attending  this  fracture  is 
that  of  its  being  occasioned  by  sudden  and  violent 
muscular  exertion  ;  and  it  will  be  recollected  that 
from  the  inner  condyle  those  powerful  muscles 
which  constitute  the  bulk  of  the  fleshy  substance 
of  the  ulnar  aspect  of  the  forearm  have  their 
principal  origin.  The  way  in  which  the  muscles 
of  the  inner  condyle  are  involuntarily  thrown 
into  such  sudden  and  excessive  action  I  take  to 
be  this :  the  endeavor  to  prevent  a  fall  by  stretch- 
ing out  the  arm,  and  thus  receiving  the  per- 
cussion from  the  weight  of  the  body  on  the 
hand."2 

It  is  a  fact,  perhaps  of  some  significance  in 
this  connection,  that  most  of  these  fractures 
occur  in  children,  before  the  union  of  the  epi- 
physis is  completed,  when  muscular  contraction 
might  more  often  prove  adequate  to  its  separa- 
tion, and  when  the  epicondyle  is  less  prominent, 
and,  therefore,  less  exposed  to  direct  blows  than  in  adult  life;  thus,  of 
five  fractures  which  I  have  distinctly  recognized  as  fractures  of  the 
epicondyle,  all,  except  one,  occurred  between  the  ages  of  two  and 
fifteen  years.  But  then  it  is  equally  true  that  a  large  majority  of  all 
the  fractures  of  the  internal  condyle,  including  those  which  enter 
the  articulation,  as  well  as  those  which  do  not,  belong  to  childhood 

•  "  On  a  Particular  Fracture  of  the  Inner  Condyle  of  the  Humerus,"  by  Benja- 
min Granger,  Surgeon,  Burton-upon-Trent.  Op.  cit.,  vol.  xiv.  pp.  196-201,  April, 
1818. 

e  Ibid.,  p.  196. 


Fracture  of  internal  epicon 
dyle. 


FRACTUEES    OF    THE    INTERlSrAL    EPICONDYLE.  257 

and  youth.  I  have  seen  but  two  exceptions  in  fifteen  cases.  Since, 
then,  direct  blows  generally  produce  those  fractures  which  penetrate 
the  joint,  no  good  reason  can  be  shown  why  they  should  not  produce 
fractures  of  the  epicondyle.  One  of  the  exceptions  to  which  I  have 
referred  as  not  having  occurred  in  early  life,  is  sufficiently  rare  to  en- 
title it  to  especial  notice. 

On  the  16th  of  May,  1856,  a  laborer,  thirty-four  years  of  age,  fell 
from  an  awning  upon  the  side-walk,  dislocating  the  radius  and  ulna 
backwards ;  the  dislocation  was  immediately  reduced  by  a  woman  who 
came  to  his  assistance,  but  when  he  called  on  me  soon  after,  I  found 
a  small  fragment  of  the  inner  condyle,  probably  the  epicondyle  alone, 
broken  off  and  quite  movable  under  the  finger.  It  was  slightly  dis- 
placed in  the  direction  of  the  hand. 

I  could  not  learn  positively  whether  in  falling  he  struck  the  elbow 
or  the  hand,  but  there  was  presumptive  evidence  that  he  struck  the 
hand ;  if  so,  then  probably  the  fracture  was  the  result  of  muscular 
action,  which  is  the  more  extraordinary  as  having  taken  place  in  a 
man  of  his  age. 

It  is  pretty  certain,  however,  that  the  theory  of  causation  adopted 
by  Granger  is  too  exclusive.  A  lad  was  brought  to  me  in  October, 
1848,  aged  eleven,  who  had  just  fallen  upon  his  elbow,  the  blow  having 
been  received,  as  he  affirmed,  and  as  the  ecchymosis  showed  pretty 
conclusively,  directly  upon  the  inner  condyle.  The  fragment  was 
quite  loose,  and  crepitus  was  distinct.  He  could  flex  and  extend  the 
arm,  and  rotate  the  forearm,  without  pain  or  inconvenience.  I  am 
quite  sure  the  fracture  did  not  extend  into  the  joint ;  the  result  seemed 
also  to  confirm  this  opinion,  for  in  three  months  from  the  time  of  the 
accident  the  motions  of  the  elbow-joint  were  almost  completely  re- 
stored. 

Indeed,  Mr.  Granger  has  failed  to  establish,  by  any  particular  proofs, 
that  in  more  than  one  or  two  of  his  cases  the  fracture  was  the  result 
of  muscular  action  ;  but,  on  the  contrary,  I  am  disposed  to  infer,  from 
the  violent  inflammation  which  generally  ensued  in  his  cases,  from 
the  frequency  of  ecchymosis,  and  especially  from  the  injury  done  to 
the  ulnar  nerve  in  at  least  three  instances,  that  most  of  them  were 
produced  by  direct  blows  inflicted  from  below  in  the  fall  upon  the 
ground.  Fractures  produced  by  muscular  action  are  seldom  accom- 
panied with  much  inflammation  or  effusion  of  blood,  and  it  is  much 
more  probable  that  the  ulnar  nerve  should  have  been  maimed  by  the 
direct  blow  which  caused  the  fracture,  than  by  the  displacement  of  the 
epiphysis,  which  is,  as  we  shall  presently  show,  almost  always  carried 
downwards,  and  oftener  slightly  forwards  than  backwards.  It  is  only 
when  the  fragment  is  forced  directly  backwards  that  the  ulnar  nerve 
could  be  made  to  suffer ;  a  direction  which,  it  does  not  seem  to  me,  it 
could  ever  take  from  muscular  action  alone. 

Direction  of  Displacement,  Symptoms,  &c. — I  have  seen  this  fragment 
displaced  in  the  direction  of  the  hand,  or  downwards,  very  manilcstly, 
twice,  and  in  two  other  examples  a  careful  measurement  showed  a 
slight  displacement  in  the  same  direction.  The  greatest  displacement 
occurred  in  a  boy  fifteen  years  old,  who  was  brought  to  me  from  St. 


258  FEACTURES    OF    THE    HUMERUS. 

Catharine,  Canada  West.  He  had  fallen  upon  his  arm  in  wrestling, 
and  his  surgeon  found  a  dislocation  of  the  bones  of  the  elbow-joint, 
which  he  immediately  reduced.  The  fracture  was  not  at  that  time 
detected,  the  arm  being  greatly  swollen.  No  splints  were  applied.  It 
was  three  months  after  the  accident  when  I  saw  him,  at  which  time  I 
found  the  internal  epicondyle  broken  ofi'  and  removed  downwards 
toward  the  hand  one  inch  and  a  quarter;  and  at  this  point  it  had 
become  immovably  fixed.  Partial  anchylosis  existed  at  the  elbow- 
joint,  but  pronation  and  supination  were  perfect. 

In  one  instance  I  believed  the  fragment  to  be  carried  about  three 
lines  upwards  and  two  backwards  toward  the  olecranon;  in  each  of 
the  other  examples  the  fragment  has  not  seemed  to  suffer  any  sensible 
displacement. 

Granger  found,  also,  in  the  five  examples  which  came  under  his 
notice,  the  epicondyle  carried  toward  the  hand,  with  more  or  less 
variation  in  its  lateral  position,  so  that  while  in  some  instances  it 
touched  the  olecranon,  in  others  it  was  removed  an  inch  or  more  in 
the  opposite  direction. 

It  is  probable  that,  except  where  controlled  by  the  force  and  direc- 
tion of  the  blow,  or  by  some  complications  in  the  accident,  the  frag- 
ment, if  displaced  at  all,  always  moves  downwards  towards  the  hand, 
or  downwards  and  a  little  forwards,  in  the  direction  of  the  action  of 
the  principal  muscles  which  arise  from  this  epiphysis ;  and  when  the 
fracture  or  separation  is  the  result  of  muscular  action  alone,  this  form 
of  displacement  seems  to  me  to  be  inevitable.  In  addition  to  the 
mobility,  crepitus,  and  generally  slight  displacement  of  the  fragment, 
which  are  the  principal  signs  of  this  fracture,  it  may  be  noticed  that 
there  is  usually  some  embarrassment  in  the  motions  of  the  elbow-joint, 
which  may  be  due  in  part  to  the  swelling,  and  in  part  to  the  detach- 
ment of  the  point  of  bone  from  and  around  v/hich  most  of  the  pro- 
nators and  flexors  of  the  forearm  have  their  rise.  In  one  instance, 
already  quoted,  that  of  the  lad  aged  eleven  years,  who  broke  the 
epicondyle  from  a  direct  blow,  the  motions  of  pronation,  with  flexion, 
were  not  at  all  impaired,  neither  immediately  nor  at  any  subsequent 
period,  but  the  fragment  was  never  sensibly,  or  only  very  slightly, 
displaced. 

Granger  has  recorded  another  class  of  symptoms,  to  which  I  have 
already  alluded,  his  explanation  of  which,  however,  I  am  not  prepared 
to  admit.  One  of  these  cases  he  describes  as  follows :  A  boy,  eight 
years  old,  fell  with  violence,  and  broke  oft"  completely  the  whole  of 
the  inner  epicondyle  of  the  right  humerus.  The  lad  said  he  had 
fallen  on  his  hand.  The  fragment  was  displaced  toward  the  hand. 
Severe  inflammation  followed,  but  he  recovered  the  free  and  entire 
use  of  the  elbow-joint  in  less  than  three  months  after  the  accident. 
No  splints  or  bandages  were  ever  employed. 

From  the  moment  of  the  accident,  the  little  finger,  the  inner  side  of 
the  ring  finger,  and  the  skin  on  the  ulnar  side  of  the  hand,  lost  all 
sensation.  The  abductor  minimi  digiti  and  two  contiguous  muscles 
of  the  little  finger  were  also  paralyzed.  This  condition  lasted  eight  or 
ten  years,  after  which  sensation  and  motion  were  gradually  restored 


FRACTUEES    OF    THE    INTERNAL    EPICONDYLE,  259 

to  these  parts.  As  a  consequence  of  this  paralyzed  condition  of  the 
ulnar  nerve,  also,  successive  crops  of  vesications,  about  the  size  of  a 
split  horse-bean,  commenced  to  form  on  the  little  finger  and  ulnar 
edge  of  the  hand  some  weeks  after  the  accident,  leaving  troublesome 
excoriations.  This  eruption  did  not  entirely  cease  for  two  or  three 
months. 

In  two  other  cases,  Mr.  Granger  remarks  that  he  has  found  "  the 
same  paralysis  of  the  small  muscles  of  the  little  finger,  the  same  loss 
of  feeling  in  the  integuments,  and  the  same  succession  of  crops  of 
vesicles  on  the  affected  parts  of  the  hand,  as  is  described  to  have 
occurred  in  the  preceding  case." 

Without  intending  to  intimate  a  doubt  of  the  accuracy  of  Mr.  Gran- 
ger's statement,  that  such  phenomena  have  followed  in  three  cases  out 
of  the  five  which  he  has  seen,  I  must  express  my  belief  that  it  was 
only  a  remarkable  concurrence  of  circumstances,  since  the  same  phe- 
nomena have  never  been  seen  by  myself,  nor  do  I  know  that  they 
have  been  observed  by  any  other  surgeon. 

Results. — As  in  all  other  accidents  about  the  elbow-joint,  a  tem- 
porary rigidity  is  almost  inevitable.  The  mere  confinement  of  the 
arm  in  a  flexed  position  is  sufficient  to  determine  this  result  without 
the  interposition  of  a  fracture  ;  but  when  inflammation  occurs,  more  or 
less  contraction  of  the  tendons,  muscles,  &c.,  about  the  joint  must  en- 
sue. To  this  circumstance,  therefore,  added  to  the  confinement,  rather 
than  to  the  fracture,  will  be  due  the  anchylosis.  If  the  fragment  is 
not  displaced,  the  fracture  cannot  certainly  be  responsible  for  the  loss 
of  motion,  since  it  does  not  in  any  way  involve  the  joint ;  and  if  dis- 
placement exists,  its  ultimate  effect  in  diminishing  the  power  of  the 
muscles  which  arise  from  the  epiphysis  must  be  only  trivial  and 
scarcely  appreciable.  We  might,  therefore,  reasonably  conclude  that 
where  the  accident  has  been  properly  treated,  permanent  anchylosis 
would  be  the  exception,  and  not  the  rule.  This  view  of  the  matter 
seems  also  to  be  sustained  by  the  recorded  results.  In  Granger's  cases, 
the  full  range  of  flexion  and  extension  of  the  forearm  has  been  finally 
restored,  or  with  so  trifling  an  exception  as  not  to  be  observable  with- 
out close  attention,  in  every  instance ;  except  in  the  one  already 
mentioned,  which  was  originally  complicated  with  dislocation;  and 
even  in  this  case  the  ultimate  maiming  was  inconsiderable.  Malgaigne, 
who  says  "  it  ought  to  be  understood  that  in  this  accident  articular 
rigidity  is  almost  inevitable,"  seems  nevertheless  to  admit  the  justness 
of  Granger's  observations  as  to  the  final  result,  if  the  proper  means 
are  employed  to  prevent  it.  I  have  myself  found  only  once  any  con- 
siderable impairment  of  the  motions  of  the  joint  after  the  lapse  of  a 
lew  years. 

Treatment. — This  accident  does  not  constitute  an  exception  to  the 
rule  which  experience  has  established,  that  epiphyseal  projections 
when  once  displaced  can  seldom  be  restored  completely  to  position  or 
maintained  in  position,  until  a  bony  union  is  consummated.  Granger 
remarks :  "  I  have  purposely  avoided  saying  one  word  about  replacing 
the  detached  condyle  (epicondyle),  and  for  these  reasons :  during  the 
state  of  tumefaction  of  the  limb,  no  means  could  be  adopted  for  con- 


260 


FRACTURES    OF    THE    HUMERUS, 


fining  the  retracted  condyle  in  its  place,  beyond  that  of  the  relaxation 
of  the  muscles;  and  both  before  the  tumefaction  has  commenced,  and 
after  it  has  subsided,  all  endeavors  to  replace  the  condyle,  or  even  to 
change  the  position  of  it,  have  failed."  He  even  proceeds  so  far  as  to 
declare  that  while  attention  ought  to  be  given  to  the  reduction  of  the 
inflammation  by  appropriate  means,  we  ought,  nevertheless,  to  instruct 
the  patient  to  flex  and  extend  the  arm  daily  from  the  moment  the  ac- 
cident occurs  until  the  cure  is  completed,  and  without  any  regard  to 
the  consolidation  of  the  fragment;  "the  exercise  of  the  joint  in  this 
manner  must  constitute  the  principal  occupation  of  the  patient  for 
several  weeks ;  and  should  it  be  remitted  during  the  formation  and 
consolidation  of  the  callus,  much  of  the  benefit  which  may  have  been 
derived  from  this  practice  will  be  lost,  and  will  with  difi&culty  be  re- 
gained." 

With  only  slight  qualifications  I  would  adopt  the  advice  of  Mr. 
Granger.  The  limb  ought,  at  first,  to  be  placed  in  a  position  of  semi- 
flexion, so  that  if  anchylosis  should  unfortunately  ensue,  it  should  be 
in  the  condition  which  would  render  it  most  serviceable,  and  also 
because  in  this  position  the  muscles  which  tend  to  displace  the  frag- 
ment would  be  most  completely  relaxed.  While  thus  placed,  an 
attempt  ought  to  be  made,  b}''  seizing  the  epiphysis,  to  restore  it  to 
position  ;  and  if  the  effort  succeeds,  as  it  certainly  is  not  very  likely  to 
do,  a  compress  and  roller  ought  to  be  so  applied  as  to  maintain  it  in 
position ;  provided,  always,  that  it  shall  not  be  found  necessary  to 
apply  the  roller  so  tight  as  to  endanger  the  limb,  or  increase  the  in- 
flammation. An  angular  splint  would  be  an  almost  indispensable 
part  of  the  apparel,  at  least  with  children,  where  this  indication  is  in 
view.  In  no  case,  however,  ought  more  than  seven  or  fourteen  days 
to  elapse  before  all  bandaging  and  splinting  should  be  abandoned, 
and  careful  but  frequent  flexion  and  extension  be  substituted. 

In  three  cases  seen  by  me,  a  displacement  of  the  fragment,  either 
forwards  or  backwards,  has  occurred  whenever  the  arm  was  flexed, 
and  it  has  been  necessary,  therefore,  to  treat  the  case  with  the  arm  in 
a  straight  position.     These  are  plainly  only  exceptions  to  the  rule. 


Fior.  80. 


Fracture   of  external  epi- 
condyle. 


§  9.  Fractures  of  the  External  Epicondyle. 

{Epicondyle,  Chaussier.) 

I  have  only  mentioned  this  supposed  fracture, 
of  which  some  writers  have  spoken  as  a  fact,  in 
order  that  I  may  declare  my  conviction  that  its 
existence  has  never  been  made  out.  If  we  admit 
the  possibility,  that,  while  in  a  state  of  epiphysis, 
it  might,  like  the  corresponding  internal  epi- 
physis, be  separated  by  muscular  action,  we 
must  yet  deny  its  probability,  since  it  is  so  ex- 
ceedingly small;  and  we  must,  for  the  same 
reason,  be  permitted  to  doubt  whether  the  fact 
of  its  separation  could  be  recognized  in  the 
living  subject.  Moreover,  if  a  true  fracture 
occurs  at  this  point  as  the  result  of  external 


FRACTURES    OF    THE    INTERNAL    CONDYLE. 


261 


violence,  it  is  sufficiently  plain,  from  an  examination  of  the  anatomical 
structure,  that  it  must  more  or  less  extend  into  the  joint  and  involve 
the  condyle  itself. 


Fi?.  81. 


Fracture  of  internal  con- 
dyle. 


§  10.  Fractures  op  the  Internal  Condyle.     {Trochlea,  Chaussier.) 

B.  Cooper,  South ,  Sir  Astley  Cooper,  and  others,  speak  of  fracture 
of  the  internal  condyle  as  very  common,  and  more  so  than  fracture 
of  the  external  condyle;  while  Malgaigne,  who 
admits  its  existence,  has  never  met  with  a  single 
living  example,  and  regards  its  occurrence  as 
exceedingly  rare.  In  a  record  of  fifteen  frac- 
tures, I  have  found  no  difficulty  in  recognizing 
five  as  fractures  of  the  inner  condyle :  five,  I 
have  already  said,  were  fractures  of  the  epicon- 
dyle,  and  the  remainder  were  undetermined, 
while  my  records  furnish  eighteen  examples  of 
undoubted  fractures  of  the  external  condyle.  It 
is  probable  that  Sir  Astley  did  not  intend  to 
make  any  distinction  between  fractures  of  the 
condyle  and  epicondyle,  and  this  might  explain 
somewhat  his  opinion  of  the  relative  frequency 
of  these  accidents ;  but  even  rejecting  this  im- 
portant distinction,  it  has  happened  to  me  to  see 
more  examples  of  fracture  of  the  outer  condyle 
than  of  the  inner. 

Causes. — It  has  already  been  stated  that  fractures  of  the  internal 
condyle,  as  well  as  fractures  of  the  epicondj^le,  belong  almost  exclu- 
sively to  infancy  and  childhood,  only  two  instances  having  come  under 
my  notice  after  the  eighteenth  year  of  life. 

I  have  seen  no  instance  which  could  be  traced  to  any  other  cause 
than  a  direct  blow,  such  as  a  fall  upon  the  elbow,  the  force  of  the 
concussion  being  received  directly  upon  the  condyle. 

Line  of  Fracture,  Displacement,  Symptoms. — The  direction  of  the 
line  of  fracture  is  tolerably  uniform,  namely,  commencing  about  one- 
quarter  or  half  an  inch  above  the  epicondyle,  it  extends  obliquely 
outwards  through  the  olecranon  and  coronoid  fossae,  and  enters  tlie 
joint  through  the  centre  of  the  trochlea. 

Displacement  of  the  lower  fragment  can  take  place  only  in  a  direc- 
tion upwards,  backwards,  forwards,  and  inwards  (to  the  ulnar  side). 
The  fragment  cannot  be  carried  downwards,  in  the  direction  of  the 
hand,  nor  outwards,  in  the  direction  of  the  radius,  unless  the  radius 
also  is  broken  or  dislocated. 

The  most  common  form  of  displacement  is  upwards  and  backwards, 
and  perhaps  at  the  same  time  a  little  inwards;  the  ulna  remaining 
attached  to  the  lower  fragment,  and  following  its  movenaents.  I  have 
seen  one  instance  in  which  the  fragment  was  carried  directly  down- 
wards toward  the  hand,  but  this  accident  was  originally  complicated 
with  a  dislocation  of  the  radius  backwards.  The  dislocation  was 
immediately  reduced.     Five  years  after,  when  the  young   man  was 


262  FRACTURES    OF    THE    HUMERUS. 

twenty-three  years  old,  I  found  the  condyle  displaced  downwards  and 
forwards  about  half  an  inch,  so  that  when  the  forearm  was  extended 
it  became  strikingly  deflected  to  the  radial  side. 

The  symptoms  which  characterize  this  fracture  are  crepitus,  almost 
always  easily  detected;  mobility  of  the  fragment,  discovered  espe- 
cially by  seizing  upon  the  epicondyle,  or  by  flexing  and  extending 
the  arm  ;  displacement  of  the  smaller  fragment  and  a  projection  of  the 
olecranon  process,  this  latter  being  very  marked  when  the  forearm  is 
extended  upon  the  arm,  but  almost  completely  disappearing  when  the 
elbow  is  bent;  projection  of  the  lower  end  of  the  humerus  in  front 
when  the  arm  is  extended ;  the  humerus  shortened  when  measured 
along'  its  ulnar  side,  from  the  internal  epicondyle;  the  breadth  of  the 
humerus  through  its  condyles  generally  increased  slightly,  sometimes 
half  an  inch  or  more ;  if  the  lesser  fragment  is  carried  upwards,  it  will 
also  be  found  that  when  the  limb  is  extended,  the  forearm  will  be 
deflected  to  the  ulnar  side. 

Sir  Astley  Cooper  remarks  that  it  is  frequently  mistaken  for  a  dis- 
location ;  and  Thomas  M.  Markoe,  of  New  York,  has  shown  that  it  is, 
in  fact,  frequently  complicated  with  a  dislocation  of  the  head  of  the 
radius  backwards ;  indeed,  he  expresses  a  belief  that  this  dislocation 
of  the  radius  seldom  or  never  occurs  without  a  fracture  of  the  internal 
condyle.^  I  shall  refer  to  his  views  again  when  considering  disloca- 
tions of  the  head  of  the  radius. 

Results. — It  is  probable  that  in  a  majority  of  cases  no  permanent 
displacement  exists ;  although  the  irregularity  of  the  bony  deposits 
around  the  base  of  the  condyle,  which  generally  may  be  easily  felt, 
would  lead  to  a  contrary  opinion.  The  fact  that  the  lower  fragment 
usually  follows  the  motions  of  the  olecranon,  renders  its  replacement 
and  retention  comparatively  easy,  unless  some  complication  exists. 
It  is  not  from  displacement,  therefore,  so  much  as  from  permanent 
muscular,  and  especially  bony  anchylosis,  that  serious  maiming  so 
often  results.  Under  any  treatment  bony  anchylosis  will  very  often 
ensue,  and  under  improper  treatment  it  is  almost  inevitable. 

Treatment. — The  arm  must  be  immediately  flexed  to  nearly  or  quite 
a  right  angle,  when,  without  much  manipulation,  the  fragments  will 
be  made  to  resume  their  place,  A -gutta-percha,  or  felt,  right-angled 
splint,  such  as  I  have  already  directed  for  fractures  occurring  just 
above  the  condyles,  well  and  carefully  cushioned,  may  now  be  applied, 
and  secured  by  rollers.  Suitable  pads  must  also  aid  the  splint  and 
roller,  in  keeping  the  fragments  in  place.  Markoe  prefers  keeping 
the  forearm  in  a  position  about  ten  degrees  short  of  a  right  angle,  be- 
lieving that  in  this  position  the  ulna  itself  will  act  as  a  splint,  and,  by 
its  support  on  the  uninjured  portion  of  the  trochlea,  hold  in  its  place 
the  broken  condyle.  Very  properly,  also,  he  prefers  to  lay  the  angular 
splint,  made  of  tin,  and  fitted  to  the  arm  and  forearm,  upon  the  back 
of  the  limb,  instead  of  upon  the  front  or  sides.  If  it  is  upon  the  inside, 
it  covers  the  broken  condyle,  and  we  are  unable  to  know  so  well  its 

'  Markoe,  New  York  Journal  of  Medicine,  May,  1855,  p.  382,  second  series, 
vol.  xiv. 


FRACTURES    OF    THE    EXTERNAL    COXDYLE.  263 

position;  if  upon  either  side,  it  is  apt  to  press  injuriously  upon  the 
epicondyles ;  and  if  it  is  in  front,  the  fragments  cannot  be  so  well  ad- 
justed or  supported.  Upon  this  point,  however,  surgeons  are  not  very 
well  agreed,  and  no  doubt  more  will  depend  upon  the  care  with  which 
the  splint  is  applied  than  upon  the  surface  against  which  it  is  laid. 

Considerable  swelling  is  almost  certain  to  follow,  and  no  surgeon 
ought  to  hazard  the  chances  of  vesications,  ulcerations,  &c.,  by  neglect- 
ing to  open  or  completely  remove  the  dressings  every  day.  "Within 
seven  days,  and  perhaps  earlier,  passive  motion  must  be  commenced, 
and  perseveringly  employed  from  day  to  day  until  the  cure  is  accom- 
plished; indeed,  in  a  majority  of  cases  it  is  better  not  to  resume  the 
use  of  splints  after  this  period:  for,  although  at  this  time  no  bony 
union  has  taken  place,  yet  the  effusions  have  somewhat  steadied  the 
fragments,  and  the  danger  of  displacement  is  lessened,  while  the  pre- 
vention of  anchylosis  demands  very  early  and  continued  motion. 

When  the  fracture  is  compound,  or  otherwise  complicated,  these 
simple  rules  will  seldom  be  found  applicable;  indeed,  fractures  attended 
with  no  such  complications  will  occasionally  be  found  difficult  to  re- 
duce, or  to  maintain  in  position  after  reduction. 

§  11.  Fractures  of  the  External  Condyle. 

Causes. — All  the  fractures(18)of  the  external  condyle,  of  which  I  have 
a  record,  occurred  in  children  under  fourteen  years  of  age,  except  one; 
in  which  instance  a  woman,  eighty-eight  years  of  age,  fell  upon  her 
elbow  while  intoxicated,  breaking  off  the  outer  condyle.  Two  months 
after  the  accident  I  found  the  fragment  displaced  half  an  inch  upwards, 
and  firmly  united. 

In  a  large  majority  of  these  cases  the  patients  themselves  have 
affirmed,  and  the  surface  of  the  skin  has  furnished  conclusive  evidence, 
that  the  fracture  was  produced  by  a  direct  blow,  generally  by  a  fall 
upon  the  elbow. 

Line  of  Fracture,  Displacement,  and  Symptoms. — The  direction  of  the 
fracture  is  generally  such  that,  commencing  always  above  and  without 
the  capsule,  it  descends  obliquely  and  enters  the  joint  either  just  within 
or  through  the  "  small  head"  or  articulating  surface  upon  which  the 
radius  is  received ;  or  else  it  penetrates  more  deeply  in  its  progress, 
and  passing  through  the  olecranon  fossa,  it  enters  the  joint  through 
the  middle  of  the  trochlea. 

In  the  first  of  these  classes  of  examples,  which  I  think  also  is  the 
most  common,  the  condyle  alone  is  broken  off,  and  it  is  liable  only  to 
become  displaced  backwards,  forwards,  or  outwards;  generally,  I  have 
found  it  displaced  a  little  outwards  sufficiently  to  increase  manifestly 
the  breadth  of  the  condyles;  or  it  has  been  carried  backwards;  once 
slightly  forwards;  it  is  also,  in  some  cases,  carried  upwards  in  a  small 
degree,  although  the  action  of  the  supinators  and  extensors  would  seem 
to  render  a  downward  displacement  more  common.  These  displace- 
ments are  usually  not  considerable,  and  in  a  few  cases  there  is  none  at 
all.  Whatever  may  be  the  direction  or  degree  in  which  the  fragment 
is  moved,  however,  the  head  of  the  radius  is  found  almost  always  to 


264 


FRACTURES    OF    THE    HUMERUS. 


Fracture  of  the  external 
condyle. 


accompany  it;  but  in  the  case  whicli  I  am  about  to  relate,  tlie  bead 
of  the  radius  became  completely  separated  from  the  condyle. 

Frederick  Keaffer,  set.  11,  fell  from  a  load  of  hay,  and  he  is  confident 
that  he  struck  the  ground  with  the  back  of  his  elbow.  Six  hoars 
after  the  accident,  he  was  brought  to  me  by  the 
physician  who  was  first  called  to  him.  The  arm 
was  much  swollen,  and  the  external  condyle  could 
not  be  distinctly  felt,  but  when  pressure  was  made 
directly  upon  it,  crepitus  and  motion  became  mani- 
fest. The  head  of  the  radius  was  at  the  same  time 
dislocated  backwards,  and  separated  entirely  from 
the  condyle;  its  smooth  button-like  head  being 
very  prominent.  It  is  difficult  to  conceive  how 
a  blow  from  behind  should  leave  the  head  of  the 
radius  dislocated  backwards,  or  how  the  radius 
could  have  separated  from  the  broken  condyle ; 
but  as  the  examination  was  repeated  several 
times,  and  while  the  patient  was  under  the  influ- 
ence of  ether,  I  have  no  doubt  of  the  fact.  Several 
other  surgeons  who  were  present  concurred  with 
me  in  opinion  fully. 
While  prosecuting  the  examination,  I  reduced  the  dislocation  of  the 
radius,  but  it  would  not  remain  in  place  a  moment  when  pressure  or 
support  was  removed.  The  lad  recovered  with  a  very  useful  arm,  the 
motions  of  flexion  and  extension,  with  pronation  and  supination,  after 
the  lapse  of  a  year,  being  nearly  as  complete  as  before  the  accident ; 
the  radius  remaining  unreduced. 

Sometimes  it  will  be  noticed  that  while  the  portion  of  the  condyle 
which  is  attached  to  the  radius  falls  backwards,  its  upper  and  broken 
extremity  pitches  forwards;  and  this  attitude  it  is  especially  prone  to 
assume  when  the  forearm  is  extended. 

It  is  even  possible,  when  the  fracture  traverses  the  trochlea,  for  the 
ulna  also  to  become  displaced  backwards  along  with  the  radius  and 
the  lesser  fragment. 

Crepitus,  which  is  usually  very  distinct,  is  most  easily  obtained  by 
rotating  the  radius,  or  by  seizing  upon  the  condyle  with  the  thumb 
and  fingers,  and  moving  it  backwards  and  forwards. 

Residts. — Ordinarily,  this  fragment  unites  promptly,  and  by  the 
interposition  of  a  bony  callus ;  but  in  four  cases,  I  have  noticed  that 
either  no  union  has  occurred,  or  the  union  has  been  accomplished 
only  through  the  medium  of  fibrous  structures,  and  the  fragment  con- 
tinued afterward  to  move  with  the  radius. 

As  a  consequence,  probably,  of  the  displacement  of  the  lesser  frag- 
ment upwards,  the  forearm,  when  straightened,  is  occasionally  found 
deflected  to  the  radial  side.  The  surgeon  must  not,  however,  confound 
the  deflection  which  is  natural,  and  which  is  greater  in  some  persons 
than  in  others,  with  the  unnatural  radial  inclination  which  is  occa- 
sioned sometimes  by  this  accident.  I  have  met  with  this  phenomenon 
three  times  in  children  under  three  years  of  age,  in  one  of  which  I 
could  not  discover  that  the  condyle  was  carried  towards  the  shoulder, 


FRACTURES    OF    THE    EXTERNAL    CONDYLE.  265 

but  only  outwards;  in  each  of  the  other  cases  the  fragment  had  united 
by  ligament.     The  following  is  one  of  the  examples  referred  to : — 

A  girl,  get.  3,  fell  and  broke  the  external  condyle  of  the  left  humerus  ; 
the  fracture  extending  freely  into  the  joint ;  crepitus  distinct ;  forearm 
slightly  flexed ;  prone.  Lesser  fragment  displaced  outwards  and  a  little 
backwards,  carrying  with  it  the  radius.  On  the  second  day  I  was  dis- 
missed on  account  of  the  unfavorable  prognosis  which  I  gave,  or  rather 
because  I  refused  to  guarantee  a  perfect  limb,  and  an  empiric  was 
employed. 

July  2,  1857,  several  months  after  the  accident,  the  father  brought 
her  to  me  for  examination.  There  was  no  anchylosis,  but  the  lesser 
fragment  had  never  united,  unless  by  ligament,  moving  freely  with 
the  head  of  the  radius.  When  the  forearm  was  straightened  upon 
the  arm  it  fell  strongly  to  the  radial  side,  but  resumed  its  natural 
relation  again  when  the  elbow  was  flexed. 

Two  other  examples  are  reported  at  length  in  the  second  part  of 
my  Report  on  Deformities  after  Fractures  as  Cases  57  and  59  of  frac- 
tures of  the  humerus. 

In  one  other  example,  however,  mentioned  also  in  my  report  as 
Case  56,  the  deflection  was  to  the  opposite  side.  I  examined  the  lad 
one  year  after  the  accident,  he  being  then  five  years  old,  and  I  found 
the  external  condyle  very  prominent  and  firmly  united,  but  not  appa- 
rently displaced  in  any  direction  except  outwards.  The  radius  and 
ulna  had  evidently  suffered  a  diastasis  at  their  upper  ends,  but  all  of 
the  motions  of  the  joint  were  free  and  perfect. 

Dorsey^  speaks  of  this  lateral  inclination  as  being  always  to  the 
ulnar  side,  but  does  not  indicate  to  what  particular  fracture  of  the 
elbow  it  belongs.  He  has  also  described  a  splint,  contrived  by  Dr. 
Physick,  intended  to  remedy  the  deformity  in  question. 

Chelius  also  speaks  of  the  same  deformity  as  occurring  after  frac- 
tures of  the  internal,  but  does  not  mention  it  in  connection  with  frac- 
tures of  the  external  condyle,  that  is,  an  inclination  of  the  forearm  to 
the  ulnar  side. 

In  more  than  half  of  the  cases  of  fracture  of  this  condyle  some 
degree  of  anchylosis  has  resulted,  lasting  at  least  several  months.  I 
have  seen  it  remaining  after  a  lapse  of  from  one  to  twenty  years,  but 
generally  it  gradually  diminishes,  and,  in  a  majority  of  cases,  com- 
pletely disappears  after  a  few  years. 

Treatment. — I  do  not  know  that  I  need  add  much  to  what  has 
already  been  said  in  relation  to  the  treatment  of  fractures  of  the 
opposite  condyle,  and  at  the  base  of  the  condyles,  since  the  measures 
applicable  to  the  one  are,  in  general,  applicable  to  the  other. 

Generally,  the  forearm  ought  to  be  flexed  upon  the  arm,  especially 
with  a  view  to  overcome  the  usual  tendency  in  the  upper  end  of  the 
lower  fragment  to  pitch  forwards,  and  which  form  of  displacement  is 
greatly  increased  by  straightening  the  arm.  A  remarkable  exception 
to  this  rule,  and  one  of  two  which  I  have  seen,  must  be  mentioned. 

James  Cronyn,  aged  six,  was  brought  to  me  in  March,  1857,  having, 

'  Elements  of  Surgery,  by  Philip  Syng  Dorscy,  Phila.  ed.,  1813,  vol.  i.  p.  14G. 
16 


266  FRACTURES    OF    THE    HUMERUS. 

a  few  minutes  before,  fallen  from  a  height  of  four  or  five  feet  to  the 
ground.  His  father  said  the  elbow  had  been  broken  at  the  same  point 
two  years  before,  and  from  that  time  had  remained  stiff"  and  crooked. 
I  found  the  external  condyle  broken  offj  and,  with  the  head  of  the 
radius,  carried  backwards.  This  was  the  position  which  it  occupied 
constantly,  though  it  was  easily  restored  and  maintained  in  position 
when  the  arm  was  straight,  but  not  by  any  possible  means  when  the 
elbow  was  flexed.  I  dressed  the  arm,  therefore,  in  an  extended  posi- 
tion, with  a  long  felt  splint,  and  the  fragments  remained  well  in  place 
until  a  cure  was  accomplished. 

In  certain  exam.ples,  I  have  no  doubt  also  that  advantage  might  be 
derived  from  the  use  of  Physick's  splint,  intended  to  obviate  the  out- 
ward or  inward  inclination  of  the  forearm. 

It  is  especially  deserving  of  notice  that,  in  the  four  cases  in  which 
I  have  observed  bony  union  to  fail,  and  the  fragments  to  continue 
movable,  the  motions  of  the  elbow-joint  have,  in  a  very  short  time, 
been  completely  restored.  If  it  does  not  prove  that  Granger  was 
correct  in  his  views  as  applied  to  fractures  of  the  internal  epicondyle, 
namely,  that  it  was  of  little  or  no  consequence  whether  the  fragment 
united  or  not,  and  that  the  elbow-joint  ought  to  be  submitted  to  free 
motion  from  the  beginning  to  the  end  of  the  treatment — if  it  does  not 
absolutely  prove,  I  say,  the  correctness  of  his  views,  it  at  least  must 
abate  our  apprehensions  of  the  supposed  evil  results  of  non-union  in 
the  case  of  the  fracture  now  under  consideration. 

I  shall  take  the  liberty  of  quoting  also,  with  a  qualified  approval, 
the  opinion  of  Dr.  John  C.  Warren,  of  Boston,  as  stated  by  Dr.  Norris 
in  his  Report  on  Surgery,  made  to  the  American  Medical  Association 
in  1848. 

"In  the  treatment  of  fractures  of  the  condyles  of  the  os  humeri,  a 
course  is  usually  recommended  which  he  believes  to  be  hurtful,  inas- 
much as  it  favors  the  worst  consequences  of  the  injury,  namelj',  loss 
of  motion  in  the  joint.  By  this  mode  of  treatment,  the  fractured  piece 
becomes  sufficiently  fixed  to  create  partial  anchylosis;  and  there  is  so 
much  pain  afterwards  in  the  proposed  passive  movements  as  to  cause 
the  omission  of  these  measures  until  permanent  stiffness  takes  place. 
The  proper  course  in  the  management  of  these  accidents,  he  conceives 
to  be — 1st.  To  apply  no  splints,  but  in  the  earlier  days  to  make  use 
of  the  proper  means  to  prevent  inflammation.  2d.  To  accustona  the 
patient  to  early  and  daily  movements  of  flexion  and  extension.*  8d. 
When  the  action  of  the  joint  becomes  limited,  to  overcome  the  resist- 
ance by  force,  and  repeat  it  daily  until  the  tendency  of  the  joint  to 
stiffen  ceases. 

"The  accomplishment  of  this  process,  he  adds,  is  so  very  painful 
that  few  patients  have  courage  to  submit  to  it,  and  few  surgeons  firm- 
ness to  prosecute  it.  The  consequence  has  been  that  in  a  great  num- 
ber of  cases  the  use  of  the  articulation  to  a  greater  or  less  extent  has 
been  lost.  The  introduction  of  etherization,  by  preventing  the  pain, 
gives  us,  in  the  opinion  of  Dr.  Warren,  the  means  of  overcoming  the 
resistance.  By  its  aid  he  has  restored  the  motion  of  a  considerable 
number  of  anchylosed  elbows,  and  has  successfully  applied  the  same 


FEACTURES  OF  THE  NECK  OF  THE  RADIUS.     267 

measures  to  other  joints,  particularly  to  the  shoulder  and  knee.  This 
has  now  become  his  settled  practice,  with  the  results  of  which  he  is 
entirely  satisfied.  The  inflammation  consequent  upon  the  forced 
movements  of  an  anchylosed  joint  is  not  to  be  lost  sight  of.  By  a 
reasonable  abstraction  of  blood,  and  other  anti-inflammatory  treatment, 
he  has  never  found  it  alarming.'" 

My  respect  for  the  distinguished  surgeon  whose  opinion  is  here 
given  does  not  permit  me  to  question  the  correctness  of  his  practice; 
but  I  cannot  avoid  a  belief  that  his  language  does  not  convey  a  precise 
idea  of  his  views.  If  he  intends  to  say  that  he  would  move  the  joint 
freely  when  it  is  suffering  from  acute  inflammation,  and  when  motion 
occasions  great  pain,  I  must  protest  against  the  practice  as  likely  to 
do  vastly  more  harm  than  good  in  any  case  ;  but  if  he  would  move  the 
joint  from  the  first,  when  the  inflammation  and  swelling  are  trivial, 
and  when  it  occasions  only  an  endurable  amount  of  pain,  then  his 
views  are  just  and  his  practice  worthy  of  imitation. 


CHAPTER    XXI. 

FRACTURES    OF    THE    RADIUS. 

Of  one  hundred  and  one  fractures  of  the  radius  which  have  been 
recorded  by  me,  not  including  gunshot  fractures,  or  fractures  demand- 
ing immediate  amputation,  three  belonged  to  the  upper  third,  six  to 
the  middle  third,  and  ninety-two  to  the  lower  third.  Three  were 
compound,  and  ninety-eight  simple.  Forty-eight  are  reported  as 
occurring  in  males,  and  thirty-five  in  females ;  forty-two  as  having 
occurred  in  the  left  arm,  and  thirty-four  in  the  right. 

Fracture  of  the  neck  of  the  radius,  as  a  simple  accident,  uncompli- 
cated with  any  other  fracture  or  dislocation,  is  exceedingly  rare  ;  yet, 
owing  to  the  depth  of  the  superincumbent  mass  of  muscles,  and  the 
difficulty  of  determining,  where  so  many  bones  and  processes  approach 
each  other,  precisely  from  what  point  the  crepitus,  if  any  is  found, 
proceeds,  surgeons  have  often  been  deceived,  and  they  have  believed 
that  they  were  the  fortunate  possessors  of  this  rare  pathological  trea- 
sure, when  the  autopsy  has  too  soon  disclosed  their  error.  Both  B. 
Cooper  and  Robert  Smith  have  alluded  to  this  difficulty,  and  the  case 
reported  by  Dr.  Markoe  to  the  New  York  Pathological  Society,  and 
published  in  the  American  Medical  Monthly,  will  serve  to  illustrate 
the  same  point;  in  which  case  the  signs  of  a  fracture  of  the  radius  at 
its  neck  were  such  as  to  deceive  that  experienced  surgeon,  yet  the 
autopsy  disclosed  the  fact  that  it  was  a  dislocation  of  the  head  of  the 
radius  forwards,  with  a  fracture  of  the  ulna.  Indeed,  its  existence 
as  a  form  of  fracture  was  doubted  by  Sir  Astley  Cooper,  and  by 

'  Transactions  of  the  American  Medical  Association,  vol.  i.  p.  174. 


268 


FEACTURES    OF    THE    RADIUS. 


Fiff.  83. 


Others  has  been  actually  denied.  I  have  seen  no  specimen  obtained 
from  the  cadaver,  except  the  doubtful  one  contained  in  Dr.  Watts' 
cabinet,  and  of  which  I  have  furnished  an  account,  accompanied  with 
a  drawing,  in  my  report  to  the  American  Medical  Association,^  and 
the  specimen  owned  by  the  late  Dr.  Mutter,  of  Philadelphia,  of  which 
he  has  kindly  furnished  me  the  following  description:  "History  un- 
known. The  line  of  fracture  seems  to  have  passed  through  the  neck 
of  the  left  radius,  just  at  the  upper  extremity  of  the  bicipital  protu- 
berance. Union  with  deformity  has  resulted. 
Owing  to  the  fracture  having  taken  place 
within  the  insertion  of  the  biceps,  that  muscle 
appears  to  have  drawn  forward  and  upward 
the  lower  end  of  the  short  upper  fragment. 
In  consequence  of  this  movement,  the  articu- 
lating facet  of  the  head  of  the  radius  is  tilted 
l)ackwards,  so  as  no  longer  to  be  in  contact 
with  the  humerus.  As  a  secondary  conse- 
quence, the  anterior  edge  of  the  head  of  the 
radius  rests  permanently  against  the  articu- 
lating surface  of  the  humerus.  At  this  new 
point  of  contact  a  new  surface  of  articulation 
is  seen  to  have  been  formed,  while  the  origi- 
nal articulating  facet  is  directed  backwards, 
and  lies  at  right  angles  to  the  one  of  more 
recent  formation.  At  the  inner  edge  of  the 
new  articulation  of  the  head  of  the  radius 
with  the  humerus,  contact  with  the  ulna  has 
developed  another  surface  of  articulation. 
The  upper  and  lower  fragments  are  united 
at  an  angle,  and  the  radius  does  not  appear 
to  have  lost  in  length." 

Velpeau  has  once  demonstrated  the  exist- 
ence of  this  fracture  in  a  dissection,  but  the 
fracture  was  accompanied  with  a  fracture 
also  of  the  coronoid  process ;  and  Berard 
obtained  possession  of  a  similar  specimen. 
I  do  not  remember  to  have  seen  a  notice  of 
any  others.  Malgaigne  affirms,  with  his  usual  frankness,  that  although 
he- has  occasionally  believed  that  he  had  met  with  it,  the  autopsy, 
whenever  it  has  been  obtained,  has  shown  that  it  was  rather  a  sub- 
luxation than  a  fracture.  On  the  other  hand,  Mr.  South  calls  it  a  "  not 
unfrequent  accident,"  but  in  confirmation  of  this  declaration  he  cites 
no  examples." 

While,  therefore,  the  presence  of  what  appear  to  be  the  rational 
diagnostic  signs  has  compelled  me  to  record  one  case  as  an  uncompli- 
cated fracture  of  the  neck  of  the  radius,  and  two  others  as  fractures  at 
this  point  accompanied  either  with  a  fracture  of  the  humerus  or  a  dis- 
location of  the  ulna,  I  am  prepared  to  admit  that  some  doubt  remains 


rractuie  ol  utck  of  radius  (Mut- 
ter's cabinet.)  a.  Original  articu- 
lating facet.  h,b.  New  articulating 
facets,     c.  Pr'ojecting  fragments. 


'  Transactions,  vol.  ix.  pp.  157  and  229. 


FEACTURES  OF  THE  NECK  OF  THE  EADIUS.     269 

in  my  own  mind  as  to  whether  in  either  case  the  fact  was  clearly  ascer- 
tained ;  nor  do  I  think,  speaking  only  of  the  simple  fracture,  that  it  will 
ever  be  safe  to  declare  positively  that  we  have  before  us  this  accident, 
lest,  as  has  happened  many  times  before,  in  the  final  appeal  to  that 
court  whose  judgment  waits  until  after  death,  our  decisions  should  be 
reversed. 

ISTothing,  perhaps,  could  more  fully  illustrate  the  difficulty  of  diag- 
nosis in  the  case  of  injuries  received  in  the  neighborhood  of  the  head 
of  the  radius  than  the  testimony  given  in  the  case  of  Noyes  vs.  Allen, 
tried  in  the  Supreme  Court  at  Cambridge,  January,  1856,  before  Judge 
Bigelow.  Mr.  Noyes  injured  his  elbow,  January  7,  1854,  and  Dr. 
Allen,  who  was  called  immediately,  believed  that  the  ligaments  of  the 
joint  had  been  torn,  but  that  no  bones  were  broken  or  displaced.  On 
the  following  morning  he  was  dismissed,  and  Mr.  Noyes  went  home. 
Three  weeks  later  it  was  seen  by  Dr.  Dow,  who  also  thought  there 
was  no  fracture.  About  eight  weeks  after  the  accident  a  physician 
examined  the  arm,  and  declared  the  neck  of  the  radius  broken,  and 
the  fragments  displaced ;  and  when  the  case  was  finally  brought  to 
trial  he  testified  still  that  such  was  certainly  the  fact ;  and  five  other 
physicians,  not  one  of  whom,  however,  we  are  told,  was  a  member  of 
the  State  Medical  Society,  testified  positively  that  the  radius  was 
broken  at  its  neck,  producing  a  bony  protuberance;  that  such  an 
injury  only  could  account  for  the  symptoms  manifested  at  the  time  of 
the  accident,  and  that  no  other  fractures  or  injuries  of  the  joint  could 
explain  so  well  the  present  appearances  of  the  arm.  While,  on  the 
part  of  the  defence,  six  of  the  most  intelligent  medical  gentlemen  of 
the  State,  Drs.  Kimbal  and  Huntington,  of  Lowell,  and  Drs.  Town- 
send,  Lewis,  Clark,  and  Gay,  of  Boston,  testified  that  the  head  and 
neck  of  the  radius  were  not  displaced,  nor  was  there  any  evidence 
that  this  bone  had  ever  been  broken.  There  is  every  reason  to  believe 
that  these  latter  gentlemen  were  correct ;  yet  it  is  to  be  presumed 
that  the  gentlemen  who  first  testified  were  not  without  some  grounds 
for  their  opinions  so  confidently  expressed. 

The  case  was  given  to  the  jury  after  a  trial  of  five  days,  who 
promptly  returned  a  verdict  for  the  defendant.^ 

When  this  fracture  occurs,  the  upper  end  of  the  lower  fragment  will 
probably  be  carried  forwards  by  the  action  of  that  portion  of  the 
biceps  which  has  its  insertion  into  the  tubercle ;  and  the  displacement 
in  this  direction  must  necessarily  be  increased  in  proportion  as  the 
arm  is  straightened.  In  the  cabinet  specimen  belonging  to  Dr.  Miitter, 
the  line  of  fracture,  commencing  in  the  neck,  has  terminated  in  the 
tubercle;  consequently  the  biceps,  having  still  some  attachment  to 
the  upper  fragment  as  well  as  the  lower,  has  drawn  them  both  for- 
wards. 

The  same  anterior  displacement  I  have  noticed  in  all  of  the  sup- 
posed living  examples,  but  whether  both  fragments  or  only  one  had 
suffered  displacement  I  am  unable  to  say. 

A  girl,  aet.  11,  living  in  Ontario  Co.,  N.  Y.,  fell  from  a  tree,  and 

'  Amer.  Med.  Gazette,  vol.  vii.  p.  299. 


270 


FRACTTJEES    OF    THE    RADIUS. 


Fia;.  84. 


injured  lier  right  arm.  Her  surgeon,  who  regarded  it  as  a  fracture  of 
the  neck  of  the  radius,  reduced  the  fragments,  and  placed  the  forearm 
at  a  right  angle  with  the  arm.  On  the  twenty-eighth  day  all  dress- 
ings were  removed,  and  the  patient  was  dismissed ;  the  fragments 
seemed  to  be  in  place.  The  parents,  finding  the  elbow  stiff,  now  made 
violent  and  successful  efforts  to  straighten  the  arm. 

Fifteen  months  after  the  accident,  the  child  was  brought  to  me. 
There  was  at  this  time  a  bony  projection  in  front,  opposite  the  neck 
of  the  radius,  which  I  believed  to  be  the  point  of  fracture.  The  hand 
was  forcibly  pronated,  and  she  had  only  a  limited  amount  of  motion 
at  the  elbow-joint.  The  anchylosis  was  probably  due  to  inflamma- 
tion directly  resulting  from  the  severe  contusion;  but  it  is  quite 
probable  that  the  forward  displacement  of  the  fragments  was  alone 
due  to  the  too  early  and  too  violent  attempts  to  straighten  the  arm  ; 
at  least,  this  was  the  explanation  which  I  ven- 
tured to  give  to  the  parents  at  the  time. 

The  second  case  occurred  in  a  lad  eight  years 
old,  living  in  Wyoming  Co.,  N.  Y.  His  parents 
brought  him  to  me  ten  weeks  after  the  injury 
was  received,  and  I  then  found  the  forearm  bent 
to  a  right  angle  with  the  arm,  and  anchylosed 
at  the  elbow-joint.  The  hand  was  also  forcibly 
pronated,  and  could  not  besupinated.  In  front, 
and  opposite  the  neck  of  the  radius,  there  was 
a  distinct  bony  projection,  which  I  believed  to 
be  the  point  of  union  of  the  bony  fragments. 
The  external  condyle  seemed  also  to  have  been 
broken. 

The  third  example,  treated  originally  by  Dr. 
Nott,  of  Bufialo,  w^as  seen  by  me  six  months 
after  the  accident.  The  upper  end  of  the  lower 
fragment  seemed  to  be  displaced  forwards. 
There  was  very  little  motion  at  the  elbow-joint, 
and  both  pronation  and  supination  were  com- 
pletely lost. 

I  have  seen,  in  Dr.  Mutter's  cabinet,  two  spe- 
cimens of  fracture  of  the  outer  half  of  the  head 
of  the  radius.  In  one  case,  the  small  fragment 
is  slightly  displaced  downwards  in  the  direction 
of  the  axis  of  the  bone ;  and,  in  the  other,  the 
fragment  is  thrown  outwards,  or  to  the  radial 
side.  Both  are  firmly  united  in  their  new  po- 
sitions. 

Dr.  Hodges  presented  to  the  "Boston  Society 
for  Medical  Improvement"  a  specimen  very 
much  resembling  those  of  Dr.  Miitter's,  in  which 
case  the  patient  survived  his  injuries  only  six 
hours ;  and  in  the  examination  after  death  he 
Fracture  of  head  of  radius,     ^as  found  to  havc  also  au  obliquc  fracturc  of 

(Matter's  collection.     Speci-  i      r-^      j?    .1  ^  ^y         i-  r    n        ^ 

meu  A.,  No.  loo.)  ^hc  shait  01  the  ulna,  the  line  oi  fracture  com- 


n 


^i 


FEACTURES  OF  THE  HEAD  OF  THE  RADIUS.     271 

mencing  above  the  coronoid  process,  and  extending  obliquely  down- 
wards and  backwards.  He  remarks,  moreover,  that  he  has  three 
times  found  a  longitudinal  fracture  of  the  head  of  the  radius  asso- 
ciated with  a  fracture  of  the  coronoid  process  of  the  ulna.^  I  have 
already  observed  that  Velpeau  had  once  noticed  the  same  coincidence. 

In  the  treatment  of  fractures  of  the  neck  of  the  radius,  we  must  not 
neglect  to  flex  the  forearm  upon  the  arm,  so  as  to  relax,  as  completely 
as  possible,  the  biceps,  whose  advantageous  insertion  into  the  tubercle 
of  the  radius  would  be  certain  to  produce  displacement,  unless  this 
position  was  adopted.  A  single  dorsal  splint,  properly  padded,  should 
support  the  forearm,  while  the  surgeon,  having  placed  a  compress 
over  the  upper  end  of  the  lower  fragment,  proceeds  to  secure  the 
whole  with  a  roller. 

Especial  care  must  also  be  taken  to  prevent  the  forearm  from  being 
extended  before  the  bony  union  is  fairly  consummated,  lest  the  biceps, 
now  firmly  contracted,  should  draw  the  lower  fragment  forwards,  as 
it  must  inevitably  do  while  the  bony  union  is  imperfect;  an  accident 
which,  there  is  some  reason  to  believe,  occurred  in  one  of  the  examples 
which  I  have  already  cited. 

If  the  patient  be  a  child,  or  if  there  is  any  reason  to  suppose  that 
these  rules  will  not  be  faithfully  complied  with,  it  would  be  well  to 
secure  the  arm  in  this  position  with  a  right-angled  splint. 

When  the  fracture  occurs  in  any  portion  of  the  radius  below  the 
insertion  of  the  biceps,  and  above  the  insertion  of  the  pronator  radii 
teres,  Mr.  Lonsdale  suggests  the  propriety  of  placing  the  forearm  in  a 
condition  of  supination,  at  least  so  far  as  is  practicable,  for  the  purpose 
of  securing  a  proper  apposition  of  the  fragments.  His  argument  in 
favor  of  this  practice  is  ingenious,  and  deserves  consideration. 

When  the  bone  is  broken  anywhere  in  this  portion,  the  action  of 
the  pronators  upon  the  upper  fragment  ceases ;  while  that  of  the  biceps, 
which  is  a  powerful  supinator,  continues ;  consequently  the  upper  frag- 
ment becomes  at  once,  and  completely,  rotated  outwards  or  supinated. 
Novv,  if  the  hand,  to  which  the  lower  end  of  the  radius  alone  remains 
attached,  should  be  forcibly  pronated,  the  radius  will  also  be  rotated 
inwards  upon  its  own  axis;  and  although  it  might  be  possible  in  this 
condition  to  bring  the  broken  ends  into  contact,  and  a  bony  union, 
without  deformity,  might  be  consummated,  yet  the  power  of  supi- 
nation must  be  forever  lost;  since  the  union  has  been  effected  while 
the  head  and  upper  fragment  are  already  in  a  state  of  complete  supi- 
nation ;  and  if  such  is  the  fact,  it  is  evident  that  the  whole  bone,  to- 
gether with  the  hand,  will  be  incapable  of  any  further  supination. 

It  is  not,  indeed,  the  practice  with  any  surgeons,  so  far  as  I  know, 
to  treat  this  fracture  with  the  hand  placed  in  a  position  of  extreme 
pronation  ;  but  the  case  has  been  supposed  for  the  purpose  of  render- 
ing the  argument  more  intelligible.  The  usual  practice  is  to  place 
the  forearm  and  hand  in  a  position  midway  between  supination  and 
pronation,  and  then  to  lay  it  across  the  body  at  a  right  angle  with  the 
arm;  but  it  is  plain  that  the  same  objection,  differing  only  in  degree, 

'  Hodges,  Boston  Med.  aud  Surg^  Journ.,  Dec.  6,  1866. 


272 


FRACTURES    OF    THE    RADIUS. 


will  apply  to  this  position  as  to  that  of  pronation.  The  axes  of  the 
two  fragments  are  not  made  to  correspond,  since,  while  the  lower  frag- 
ment is  only  half  rotated  outwards,  the  upper  fragment  is  completely, 
and  the  result  of  the  union  must  be  the  loss  of  one-half  the  power  of 
supination  in  the  hand. 

It  is  only,  then,  by  complete  supination  of  the  hand  during  treat- 
ment that  this  difficulty  can  be  avoided,  and  I  have  no  doubt  that  we 
ought  to  adopt  this  plan  whenever  it  is  practicable  to  do  so,  or  when- 
ever we  are  not  hindered  by  serious  obstacles;  and  the  only  obstacle 
which  occurs  to  me  as  likely  to  interpose  itself,  is  the  practical  one 
which  most  surgeons  must  have  experienced  in  treating  all  injuries  of 
the  forearm,  whether  fractures,  or  only  severe  contusions  of  the  mus- 
cles, &c.,  namely,  the  constant  and  almost  uncontrollable  tendency 
of  the  hand  to  assume  the  prone  or  semi-prone  position.  This  is  due, 
no  doubt,  to  the  great  preponderance  of  power  in  the  pronators ;  and 
such  is  the  resistance  which  they  afford  to  supination  that  it  is  often 
quite  impossible  to  lay  the  hand  upon  its  back  while  the  forearm  is 
across  the  body,  and  if  accomplished,  the  position  generally  becomes 
in  a  few  hours  so  painful  as  to  be  intolerable.  By  extending  the 
arm,  however,  and  laying  it  upon  a  pillow,  the  hand  will  be  found 
again  to  rest  easily  upon  its  back,  because  in  this  way  we  avail  our- 
selves of  the  outward  rotation  of  the  humerus  at  the  shoulder-joint. 

Dr.  X.  C.  Scott,  formerly  Resident  Surgeon  to  the  Brooklyn  City 
Hospital,  in  his  inaugural  thesis,  submitted  in  March,  1869,  has  dis- 
cussed very  fully  the  advantages  of  this  position  in  many  fractures  of 
the  forearm,  and  he  has  devised  a  very  ingenious  mode  of  securing 
the  limb  after  supination  is  effected,  adding  also  a  moderate  amount 
of  extension  by  adhesive  plasters  and  elastic  bands. 

Fie:.  85. 


Scotfs  apparatus  for  fractures  of  the  forearm. 


Dr.  Scott  informs  me  that  he  has  treated  twenty-five  cases  very 
successfully,  at  the  Brooklyn  City  Hospital  and  elsewhere,  by  this 
method. 

It  has  already  been  stated  that  of  the  whole  number  of  fractures  of 


FEACTURES  OF  THE  HEAD  OF  THE  RADIUS. 


273 


Fi-.  86. 


Fracture  of  the  shaft  of  the  radius.     (From  Gray.) 


this  bone  recorded  bj  me,  amounting  in  all  to  one  hundred  and  one, 
only  six  belonged  to  the  middle  third.  An  observation  which  is  in 
striking  contrast  with  the  remark  of  Chelius,  that  it  is  broken  most 
frequently  in  its  middle. 

If  the  fragments  are  com- 
pletely separated  at  this 
point,  the  lower  end  of  the 
upper  half  is  drawn  forward 
by  the  action  of  the  biceps 
aided  by  the  pronator  radii 
teres,  in  case  the  fracture  is 
below  its  insertion ;  while 
the  lower  fragment  is  tilted 
toward  the  ulna  by  the  con- 
joined action  of  the  supi- 
nator radii  longus,  and  pronator  quadratus.  But  as  to  the  direction 
of  the  displacement  much  will  depend  upon  the  direction  of  the  force 
by  which  the  fracture  has  been  occasioned. 

A  laboring  man,  set.  35,  broke  the  radius  near  the  lower  end  of  the 
middle  third.  On  the  same  day  I  replaced  the  fragments  as  well  as 
I  could  in  the  midst  of  the  swelling  which  had  already  occurred,  and 
applied  two  broad  and  well-padded  splints,  one  to  the  palmar  and  one 
to  the  dorsal  surface  of  the  forearm. 

On  the  twenty-eighth  day  I  first  discovered  that  the  fragments  were 
projecting  in  front,  and  I  at  once  proposed  to  thrust  them  back  by 
force,  but  the  patient  declined  allowing  me  to  do  so.  I  then  applied 
a  compress  near  the  summit  of  the  projection,  but  not  exactly  npon 
it,  lest  it  should  cause  ulceration,  and  secured  over  this  a  firm  splint. 
At  first  this  seemed  to  produce  a  change  in  the  fragments,  but  after 
a  couple  of  weeks  I  found  there  was  no  improvement,  and  it  was  dis- 
continued. About  six  months  after  the  fracture  occurred,  this  man 
had  the  same  arm  terribly  lacerated  in  a  railroad  accident,  and  I  was 
obliged  to  amputate  near  the  shoulder-joint;  and  I  thus  obtained  the 
broken  radius.  The  bone  was  firmly  united,  but  with  an  angle,  sa- 
lient forwards,  of  about  ten  degrees.  There  was  no  inclination  toward 
the  ulna. 

My  impression  is  that  these  fragments  were  never  completely  re- 
placed, a  point  which  I  could  not  well  determine  at  first  on  account 
of  the  rapid  eS"usion.  If  they  had  been,  I  think  they  could  have  been 
retained  in  place  with  the  appliances  used.  Almost  every  day  the 
limb  was  examined,  and  as  often  as  every  fourth  or  fifth  day  the 
dressings  were  removed  and  carefully  reapplied.  And  only  once  did 
they  become  so  loose  as  not  to  afford  the  requisite  support,  and  this 
at  a  period  too  late  to  have  occasioned  the  deformity. 

We  ought  not  to  be  deceived,  therefore,  and  promise  too  confi- 
dently a  perfect  limb,  even  when  but  the  radius  is  broken,  since  we 
may  not  always  be  certain  that  the  ends  are  well  replaced,  or  perhaps 
they  may  become  displaced  subsequently,  and  in  either  case  we  are 
not  likely  to  discover  the  deformity  until  the  swelling  has  subsided, 
and  it  is  too  late  to  apply  the  remedy. 


274  FRACTUEES    OF    THE    RADIUS. 

In  the  treatment  of  fractures  of  the  middle  third,  the  same  rules, 
with  only  slight  modifications,  will  be  applicable,  as  in  fractures  of 
both  bones.  Two  straight,  long,  and  broad  splints  must  be  applied 
after  being  carefully  padded ;  and  especial  attention  should  be  paid 
to  the  tendency  of  the  fragments  to  become  displaced  forwards  and 
toward  the  ulna  through  the  action  of  both  the  biceps  and  the  prona- 
tor radii  teres;  a  tendency  which  may  in  some  measure  be  provided 
against  by  flexion  of  the  arm,  but  which  must  be  overcome  chiefly  by 
steady  and  well-adjusted  pressure,  near,  but  not  upon,  the  ends  of  the 
fragments. 

Fractures  of  the  lower  third,  occurring  above  the  line  of  Colles' 
fracture,  are  almost  as  rare  as  fractures  of  the  middle  or  upper  thirds. 
I  have  recorded  five ;  one  of  which  it  will  be  proper  to  relate  as  a 
representative  example. 

George  Vogel,  set,  30,  was  admitted  to  the  Buffalo  Hospital  of  the 
Sisters  of  Charity,  Nov.  2,  1852,  with  a  fracture  of  the  right  radius 
about  three  and  a  half  inches  above  its  lower  end.  The  hand  was 
]"»rone,  and  inclined  to  the  radial  side;  while  the  broken  ends  of  the 
radius  fell  against  the  ulna,  from  which  it  was  found  difficult  to  sepa- 
rate them.  The  lower  end  of  the  ulna  was  prominent,  and  projecting 
upon  the  ulnar  margin  of  the  hand. 

I  was  unable  completely  to  separate  the  fragments  of  the  radius 
from  the  ulna,  by  either  pressure  with  my  fingers  between  the  bones, 
or  by  seizing  upon  them  with  my  thumb  and  fingers.  Having, 
however,  adjusted  them  as  well  as  possible,  I  flexed  the  arm,  and 
applied  a  broad  and  well-padded  splint  to  the  palmar  surface  of  the 
forearm,  securing  it  in  place  with  a  paste  bandage.  These  dressings 
were  finally  removed  at  the  end  of  four  weeks,  when  I  found  scarcely 
any  displacement  or  deformity  remaining. 

Most  of  these  fractures,  when  properly  treated,  result  in  perfect 
limbs.  In  a  certain  proportion,  however,  it  will  be  found  impossible 
effectually  to  resist  the  action  of  the  pronator  radii  teres  and  of  the 
quadratus,  and  the  fragments  will  unite  at  an  angle  resting  against 
the  ulna,  and  sometimes,  by  the  interposition  of  intermediate  callus, 
they  will  become  firmly  united  to  the  ulna.  Occasionally,  also,  espe- 
cially where  the  fracture  has  been  produced  by  a  fall  upon  the  hand, 
and  the  radio-ulnar  ligaments  of  the  wrist  have  been  torn  or  stretched, 
the  lower  end  of  the  ulna  will  be  found  to  project  permanently,  and 
the  hand  to  fall  more  or  less  to  the  radial  side. 

Of  the  ninety-two  fractures  belonging  to  the  lower  third  of  the 
radius,  eighty-seven  were  near  the  lower  end,  or  within  from  half  an 
inch  to  one  inch  and  a  half  from  the  articular  surface,  all  being  in- 
cluded in  those  fractures  called  "Colles'  fractures,"  most  of  which 
were  no  doubt  true  fractures,  and  probably  a  small  proportion  sepa- 
rations of  the  epiphyses. 

In  every  instance,  except  one,  which  has  come  under  my  notice, 
where  the  cause  of  a  Colles'  fracture  has  been  ascertained,  it  has  been 
occasioned  by  a  fall  upon  the  palm  of  the  hand.  The  exceptional 
case  was  in  the  person  of  Mrs.  D.  B.,  who  fell  in  getting  out  of  a  street 
car  in  the  city  of  New  York,  May  20th,  1665,  striking  upon  the  back 


COLLES'   rRACTURE, 


275 


of  her  hand  while  the  hand  was  shut.  The  displacement  was  in  the 
same  direction  as  in  cases  caused  by  a  fall  upon  the  palm.  Eobert 
Smith  has  seen  a  similar  accident  cause  a  displacement  of  the  frag- 
ment forwards. 

Colles  described  this  fracture  as  occurring  alwa^'-s  about  one  inch 
and  a  half  above  the  carpal  end  of  the  bone  ;  but  Robert  Smith,  who 
has  carefully  examined  all  of  the  cabinet  specimens  he  could  find, 
about  twenty-three  in  number,  has  never  seen  the  line  of  fracture 
removed  farther  than  one  inch  from  the  lower  end  of  the  bone,  and 
in  several  specimens  it  was  within  one-quarter  of  an  inch  of  this 
extremity.  Dupuytren  has  also  described  the  fracture  as  occurring 
from  three  to  twelve  lines  above  the  joint.  I  think  I  have  found  the 
fracture  generally  as  low  as  these  latter  surgeons  have  placed  it,  but 
occasionally  as  high  as  it  was  placed  by  Colles. 

Fig.  87. 


Fracture  of  the  radius  near  its  lower  end. 


Case.  A  woman,  set.  40,  fell  upon  the  side-walk,  striking  upon  the 
palm  of  her  left  hand.  She  was  brought  immediately  to  my  office, 
and  I  found  the  radius  was  broken  about  one  inch  and  a  half  above 
the  wrist.  The  lower  fragment  was  tilted  back  considerably.  Hand 
prone. 

Placing  my  thumb  against  the  back  of  the  lower  fragment,  it  was 
easily  i-estored  to  position,  and  with  only  a  slight  crepitus.  When 
my  thumb  was  removed  it  manifested  no  tendency  to  displacement. 
The  arm  was  dressed  with  a  curved  palmar  splint,  secured  in  place 
with  a  roller  applied  moderately  tight.  On  the  seventh  day  a  straight 
splint  was  substituted  for  the  curved.  The  arm  was  examined  almost 
every  day,  and  the  dressings  occasionally  renewed  until  the  twenty- 
sixth  day,  when  the  splint  was  finally  removed.  The  wrist  was  at 
this  time  only  slightly  anchylosed,  and  there  seemed  to  be  no  deformity 
or  imperfection  remaining.  Passive  motion,  which  had  been  pi-actised 
at  each  removal  of  the  dressings,  was  directed  to  be  continued. 

Case.  A  boy,  set.  11,  was  brought  to  me,  having  just  fallen  from  a 
pair  of  stilts.  His  right  radius  was  broken  transversely,  three-quarters 
of  an  inch  above  the  wrist,  and  the  lower  fragment  was  much  tilted 
back;  the  lower  end  of  the  ulna  was  prominent,  and  the  hand  fell  to 
the  radial  side. 

Pushing  from  behind,  the  lower  fragment  was  made  to  resume  its 
place,  and  the  deformity  immediately  disappeared.  It  was  noticed, 
however,  that  it  required  unusual  force  to  accomplish  this,  but  it  was 
not  found  necessary  to  use  extension.  There  was  also,  accompanying 
the  reduction,  a  slight  crepitus. 


276  FRACTUEES  OF  THE  RADIUS. 

The  treatment  was  the  same  as  in  the  first  case,  except  that  the 
curved  splint  was  employed  throughout.  Little  or  no  deformity  ex- 
isted when  the  dressings  were  removed. 

Case.  George  Lofinch,  set.  42,  fell  upon  an  icy  side- walk,  striking 
upon  the  palm  of  his  left  hand.  Fracture  'three-quarters  of  an  inch 
above  the  lower  end.  Fragment  displaced  backwards.  A  friend  had 
partially  replaced  the  fragment  by  pushing  upon  it,  before  he  came  to 
me.  Within  half  an  hour  after  the  accident  he  was  at  my  office,  and 
I  restored  the  lower  end  of  the  bone  very  easily  to  place  by  pushing 
from  behind  with  my  thumb.  No  extension  was  necessary.  It  would 
not,  however,  remain  in  place  unless  the  forearm  was  pronated  so  that 
the  weight  of  the  hand  could  aid  in  the  retention. 

I  applied  my  own  palmar  splint.  The  recovery  was  rapid  and 
complete. 

Case.  Margaret  Eeed,  set.  48,  fell,  September  23,  1855,  striking  on 
the  palm  of  the  left  hand,  and  breaking  the  radius  about  one  inch  from 
its  lower  end.  One  week  after,  she  came  under  my  care  at  the  hos- 
pital. The  arm  had  been  previously  dressed  carefully  by  one  of  my 
colleagues,  with  curved  dorsal,  and  palmar  splints;  but,  on  examina- 
tion, we  found  the  fragments  a  good  deal  displaced.  It  was  found 
necessary  now  to  use  both  extension,  and  pressure  from  behind  to  re- 
store the  lower  fragment  to  position.  This  we  finally  succeeded  in 
doing,  and  immediately  splints  were  again  snugly  applied.  Two  days 
after,  on  opening  the  dressings,  the  lower  fragment  was  a  second  time 
found  displaced  backwards.  It  was  again  reduced,  but  only  by  using 
great  force.  Fifteen  days  later,  we  were  pleased  to  find  the  bone  firm 
and  without  deformity. 

Margaret  left  the  hospital  on  the  4th  of  November,  with  her  hand 
and  wrist  still  swollen,  and  with  a  good  deal  of  stiffness  at  the  elbow 
and  wrist  joints. 

Case.  Charles  Stratton,  a  healthy  and  temperate  laborer,  £et.  36. 
fell  forwards  from  a  wagon,  Nov.  22,  1854,  striking  upon  the  palm  of 
his  hand,  and  breaking  the  radius  a  little  more  than  one  inch  above 
the  joint.  I  found  the  lower  fragment  displaced  backwards,  and  it  was 
easily  reduced  by  pressure  in  the  opposite  direction.  The  forepart  of 
the  wrist  being  quite  tender  to  pressure,  the  splint  was  applied  to  the 
dorsal  surface  of  the  forearm.  The  splint  was  curved  (pistol-shaped), 
and  the  surface  which  was  applied  to  the  arm  was  padded  with  care  ; 
it  was  secured  in  place  by  a  few  light  turns  of  a  roller,  and  laid  across 
the  body  in  a  sling. 

The  arm  was  seen  by  me  on  each  of  the  succeeding  seven  days,  and 
on  the  third,  fifth,*  and  seventh  days  the  splint  was  removed  com- 
pletely ;  but  on  this  last  day  an  erysipelatous  inflammation  had  com- 
menced in  the  neighborhood  of  the  wrist.  The  splint  and  roller  were 
therefore  not  reapplied,  but  the  limb  was  laid  upon  a  broad  board, 
cushioned  and  covered  with  oiled  silk,  and  cool  water  irrigations  were 
directed.  The  inflammation  soon  subsided,  but  the  splint  was  never 
resumed,  as  the  fragments  were  found  to  stay  in  place  perfectly  with- 
out its  aid.  At  the  end  of  five  weeks,  union  seemed  to  be  consum- 
mated ;  and  one  year  later  the  bone  was  found  to  be  perfectly  straight, 


COLLES'    FRACTURE,  277 

yet  the  wrist-joint  and  the  finger-joints  remained  stiff,  so  much  so  that 
he  was  unable  to  perform  any  labor.  The  stiffness  was,  however, 
gradually  disappearing ;  while  all  swelling  and  tenderness  had  long 
ceased. 

The  observations  of  M.  Voillemier  also  have  shown  that,  instead  of 
being  oblique,  as  has  generally  been  supposed,  the  fracture  is  almost 
uniformly  transverse  from  the  palmar  to  the  dorsal  surfaces  of  the 
bone,  and  only  occasionally  slightly  oblique  in  its  other  diameter,  or 
from  the  radial  to  the  ulnar  side.  I  have  seen,  however,  in  the  mu- 
seum of  the  College  of  Physicians  of  Philadelphia,  a  specimen  of  this 
fracture  in  which  the  line  of  fracture  is  transverse,  from  side  to  side, 
but  very  oblique  from  before  backwards,  and  from  below  upwards. 
There  is  also  a  line  of  incomplete  fracture  extending  into  the  joint. 
It  is  united  by  bone,  with  the  usual  displacement  backwards. 

The  observations  of  both  R.  Smith  and  Voillemier  have  shown, 
moreover,  that  the  displacement  of  the  lower  fragment  is  seldom  suffi- 
cient to  enable  it  to  escape  completely  from  the  upper  ;  and  that  where, 
in  extremely  rare  instances,  and  in  consequence  of  extraordinary  vio- 
lence, such  complete  separation  does  occur,  a  disruption  of  those  liga- 
ments which  attach  the  lower  fragment  to  the  ulna  occurs  also,  and 
the  deformity  becomes  at  once  very  great,  so  that  it  no  longer  presents 
the  peculiar  features  of  Colles'  fracture,  but  resembles  a  dislocation. 

In  the  so-called  Colles'  fracture,  the  lower  and  outer  border  of  the 
radius,  or  its  styloid  apophysis,  is  swung  around  or  tilted,  as  it  were, 
upon  the  ulna  ;  the  lower  and  inner  border  of  the  same  fragment  being 
retained  in  place  by  the  radio-ulnar  ligaments,  which  do  not  usually 
suffer  a  complete  disruption,  but  only  a  stretching  or  partial  laceration. 
The  upper  or  broken  margin  of  the  lower  fragment,  and  also  the 
ulnar  margin,  undergo  very  little  displacement;  while  the  lower  or 
articular  surface,  and  the  radial  margin,  are  carried  backwards,  up- 
wards, and  outwards. 

Surgeons  have  spoken  of  a  falling  in  of  the  upper  end  of  the  lower 
fragment  toward  the  ulna,  as  an  almost  inevitable  result  of  the  action 
of  the  pronator  quadratus,  and  against  which  tendency  they  have 
sought  carefully  to  provide ;  but  there  is  much  reason  to  believe  that 
any  considerable  degree  of  displacement  in  this  direction  is  a  rare 
event,  and  that,  when  it  does  exist,  it  is  in  consequence  mostly  of  the 
direction  of  the  force  which  has  produced  the  fracture,  rather  than  of 
the  action  of  this  muscle,  only  a  few  of  the  fibres  of  which  are  usually 
attached  to  the  lower  fragment,  and,  in  some  instances,  when  the 
fracture  is  within  a  half  or  quarter  of  an  inch  of  the  articulation,  not 
any.  Besides,  there  is  actually  in  these  latter  cases  no  interosseous 
space  into  which  the  fragment  may  fall,  and  its  displacement  toward 
the  ulna  becomes,  therefore,  impossible. 

Still,  however,  if  one  were  disposed  to  speculate  upon  the  condition 
of  these  parts  after  the  fracture,  it  might  perhaps  be  easy  to  persuade 
ourselves  that  the  action  of  the  pronator  quadratus  upon  the  upper 
fragment,  whose  broken  extremity  was  not  completely,  or  at  all,  dis- 
engaged from  the  lower,  would  carry  both  fragments  together  toward 
the  ulna.     But  whatever  might  be  the  result  of  our  speculations,  still 


278  FRACTURES    OF    THE    RADIUS. 

the  fact,  as  proved  by  specimens,  is  not  generally  so ;  and  this  is  not 
the  first  time  that  facts  and  theories  have  disagreed. 

The  truth  is,  that  it  is  unusual  to  find  any  of  the  museum  speci- 
mens of  this  fracture  thus  united.  But  they  maybe  found  constantly 
tilted  back  in  the  manner  I  have  described,  occasionally  tilted  for- 
wards, and,  still  more  rarely,  slightly  displaced  upon  their  broken 
surfaces  antero- posteriorly. 

The  general  absence  of  this  internal  displacement  may  find  its  ex- 
planation in  the  direction  of  the  force  which  generally  produces  this 
fracture,  in  the  occurrence  of  the  fracture  sometimes  at  a  point  so  low 
as  to  render  its  displacement  in  this  direction  impossible,  and  in  the 
breadth  of  the  bone,  at  the  seat  of  the  fracture,  which  does  not  permit 
it  to  fall  laterally  without  actually  increasing  its  length  ;  a  circum- 
stance which  its  secure  ligamentous  attachment  to  the  ulna  at  its  op- 
posite extremities,  and  its  complete  apposition  to  the  wrist  and  elbow- 
joint,  do  not  allow. 

The  mistake  of  those  surgeons  who  have  attempted  to  describe  this 
fracture  has  originated  in  the  appearance  presented  in  nearly  all  re- 
cent fractures  occurring  at  this  point.  The  hand  falls  to  the  radial 
side,  and  seems  to  carry  the  lower  end  of  the  lower  fragment  with  it, 
while  the  lower  end  of  the  ulna  becomes  unnaturally  prominent  in 
front  and  to  the  ulnar  side  ;  a  condition  of  things  which  has  naturally 
enough  been  ascribed  to  the  displacement  of  the  upper  end  of  the 
lower  fragment  in  the  direction  of  the  interosseous  space. 

But  this  same  radial  inclination  of  the  hand,  and  prominence  of  the 
ulna,  are  present  frequently  when  the  radius  is  broken  at  its  lower 
end,  and  no  displacement  in  any  direction  has  taken  place ;  and  I  have 
even  observed  it  in  simple  sprains  of  the  wrist,  and  in  the  hands  of 
old  or  feeble  persons  where  all  the  ligaments  have  become  relaxed. 

It  is  seen,  however,  in  a  more  marked  degree  when  the  bone  is 
actually  both  broken  and  displaced  backwards  in  its  usual  direction. 
In  short,  the  deformity  in  question  is  due,  in  a  large  majority  of  in- 
stances, to  the  relaxation,  stretching,  or  more  or  less  disruption  of  the 
radio-ulnar  ligaments,  which  permits  the  hand  to  fall  to  the  radial 
side  by  a  simple  rotatory  movement  over  its  articular  surface.  For 
this  reason,  also,  because  these  ligaments  once  lengthened  or  broken 
can  never,  or  only  after  a  lapse  of  many  years,  be  completely  restored, 
this  deformity  may  be  expected,  in  a  certain  number  of  cases,  to  con- 
tinue, however  exact  and  perfect  may  be  the  bony  union. 

It  must  be  added,  however,  that  so  long  as  the  tilting  of  the  frag- 
ment remains,  the  articular  surface  is  actually  presenting  somewhat  to 
the  radial  side.  While  in  the  normal  condition  it  presents  downwards, 
forwards,  and  inwards,  it  now  presents,  when  the  displacement  is  con- 
siderable, downwards,  backwards,  and  outwards. 

Diday  maintained  that  there  existed  usually  in  this  fracture  an  over- 
lapping or  shortening  of  the  bone  in  its  entire  diameter,  and  Voillemier 
thought  that  the  specimens  which  he  had  examined  proved  that  an 
impaction  was  almost  universal. 

13oth  of  these  opinions  have  been  combated  by  Robert  Smith;  the 
shortening  observed  by  Diday  being  found  only  on  that  side  of  the 


COLLES     FEACTURE. 


279 


bone  to  which  the  hand  inclines,  and  being,  according  to  R.  Smith, 
the  result  of  the  motion  of  the  lower  fragment  already  described ;  and 
the  appearance  of  impaction  being  due  to  the  ensheathing  callus  which 
is  deposited  usually,  if  the  displacement  is  allowed  to  continue,  in  the 
retiring  angle  opposite  the  seat  of  fracture. 

These  are  questions,  however,  requiring  for  their  decision  a  very 
careful  study  of  specimens,  and  in  relation  to  which  farther  observa- 
tions may  be  necessary.  Indeed,  some  recent  observations  made  by 
Mr.  Callender,  of  Saint  Bartholomew's  Hospital,  London,  go  far  to 
sustain  the  opinion  of  Diday,  that  some  impaction  generally  exists, 
but  rather  upon  the  posterior  margin  than  upon 
either  the  radial  or  ulnar  side.' 

Meanwhile  there  is  no  doubt  that  occasional  ex- 
amples may  be  found  illustrating  one  or  more  of  all 
these  varieties  of  displacement,  and  that  to  the  im- 
paction is  sometimes  added  a  comminution  of  the 
lower  fragment,  the  lines  of  the  fracture  extending 
freely  into  the  joint.  One  of  the  most  curious  exam- 
ples of  which  has  been  reported  by  Dr.  Bigelow, 
of  Boston.  The  patient  had  fallen,  and  being  other- 
wise seriously  injured,  ultimately  died  in  the  Massa- 
chusetts Hospital.  At  first  he  had  only  complained 
of  lameness  at  the  wrist,  as  if  it  had  been  severely 
sprained;  but  at  the  end  of  several  days  the  joint 
became  swollen,  and  from  the  persistence  of  the 
swelling  Dr.  Bigelow  was  led  to  diagnosticate  a 
stellate  crack  in  the  articulating  extremity  of  the 
radius,  he  having  met  with  a  similar  case  two 
years  before,  when  a  patient  with  the  same  symp- 
toms had  died  of  other  injuries,  and  exhibited  a 
crack  in  the  same  place,  but  less  extensive  than 
in  this  case.  There  was  found,  in  this  last  example,  a  star-shaped 
fissure  on  the  articulating  surface,  without  displacement.  These  fis- 
sures penetrated  the  shaft  for  an  inch  or  more.  Dr.  Bigelow  thought 
that  the  bones  of  the  wrist  acted  as  a  wedge  to  spread  the  correspond- 
ing hollow  of  the  articulating  extremity  ;  and  that  this  specimen  would 
explain  the  persistence  of  some  cases  of  sprained  wrist.^ 

Robert  Smith  has  described  a  fracture  occurring  at  the  same  point, 
and  probably  possessing  nearly  the  same  characters  as  Colles'  fracture ; 
in  which  the  lower  fragment  is  thrown  forwards  instead  of  backwards, 
and  which  has  generally  been  the  result  of  a  fall  upon  the  back  of 
the  hand.  There  is  no  such  specimen,  however,  in  any  of  the  patho- 
logical collections  in  Dublin,  nor  has  Mr.  Smith  ever  seen  a  specimen 
obtained  from  the  cadaver,  although  he  reports  a  case  which  fell  under 
his  observation  in  practice. 

I  have  myself  seen  one  such  case,^  but  I  regret  to  say  that   my 


Bigelow's  case  of  com- 
minuted fracture  of  the 
lower  end  of  the  radius. 


'  Callender,  St.  Barth.  Hosp.  Eep.,  p.  281,  ISG."). 

2  Boston  Med.  and  Surg.  Joiirn.,  vol.  Iviii.  p.  99. 

3  Trans.  Am.  Med.  Assoc,  vol.  ix.  p.  145. 


280  FRACTURES    OF    THE    RADIUS. 

examination  of  the  condition  of  the  arm  was  not  such  as  to  enable 
me  to  add  anything  to  the  information  already  possessed  upon  this 
subject ;  indeed,  until  we  have  an  opportunity  of  studying  it  in  the 
cadaver,  we  cannot  speak  very  definitely  of  its  anatomical  characters. 

Nelaton  observes  that  all  the  varieties  of  this  fracture  which  he  has 
seen  are  often  accompanied  with  fracture  of  the  styloid  apophysis  of 
the  ulna,  and  with  a  tearing  of  the  triangular  ligament.  I  am  not 
aware  that  any  other  writer  has  made  the  same  observation  in  relation 
to  the  frequent  occurrence  of  a  fracture  of  the  styloid  apophysis  of  the 
ulna,  and  I  think  the  accident  is  not  so  common  as  the  remark  of 
Nelaton  would  lead  us  to  suppose. 

Dr.  Butler,  House  Surgeon  to  the  Brooklyn  Hospital,  reports  a  case 
of  fracture  of  the  right  radius  at  the  junction  of  the  middle  and  lower 
thirds,  accompanied  with  a  fracture  also  of  the  styloid  apophysis  in 
the  same  bone.  Tiie  accident  occurred  in  a  lad  fourteen  years  old, 
who  had  fallen  from  a  height  of  thirty  feet  upon  the  pavement.  The 
lower  fracture  commenced  at  the  base  of  the  styloid  process  of  the 
radius,  and  extended  down  obliquely  into  the  wrist-joint,  breaking  off 
about  one-fifth  of  the  articular  surface.  The  process  was  drawn  up 
on  the  posterior  surface  of  the  radius,  about  one  inch  and  a  half,  by 
the  supinator  radii  longus  muscle.  It  was  movable,  but,  in  consequence 
of  the  contusion  and  swelling,  could  not  be  returned  to  its  place.  The 
hand  occupied  the  same  position  that  it  does  in  Colles'  fracture. 

On  the  eighth  day  an  attempt  was  made  to  force  down  the  process 
with  a  compress  secured  by  adhesive  plaster  straps  ;  but  it  could  not 
be  done.  The  hand  and  arm  were  confined  also  to  a  pistol-shaped 
splint ;  ulcerations  ensued  from  the  pressure  of  the  compress,  and  the 
process  was  laid  bare,  but  it  finally  became  united  in  its  abnormal 
position ;  the  motions  of  the  wrist,  however,  were  not  impaired,  and 
the  power  of  pronation  and  supination  soon  returned.' 

I  believe  I  have  seen  two  examples  of  a  fracture  commencing  on 
the  radial  side  of  the  bone  and  terminating  in  the  joint,  the  separated 
fragment  including  considerable  more  than  the  apophysis  ;  but  neither 
of  these  cases  has  been  verified  by  an  autopsy.  They  are  treated  at 
length  in  the  preceding  edition  of  this  book. 

Kecently  Dr.  E.  Moore,  of  Eochester,  N.  Y.,  has  demonstrated  by 
examinations  upon  the  cadaver  and  by  experiment,  that  in  a  certain 
proportion  of  cases  the  internal  lateral  ligament,  and  the  triangular 
fibro-cartilage  having  given  way  under  the  force  which  has  occasioned 
the  fracture,  the  styloid  process  is  thrust  under  the  annular  ligament 
and  imprisoned;  in  fact,  the  ulna  becomes  dislocated,  and  is  retained  by 
the  annular  ligainent  in  its  new  position.  Nor  can  the  reduction  of  the 
fracture  be  accomplished  until  the  ulna  is  released  from  its  imprison- 
ment. Eeduction  is  to  be  accomplished  by  extension  and  partial  cir- 
cumduction ;  the  hand  being  grasped  firmly  and  extended  first  to  the 
radial  side,  then  backwards  to  the  ulnar  side,  and  finally  forwards,  or 
in  the  position  of  flexion.  During  the  entire  manoeuvre  the  wrist  is 
held  firmly  by  the  opposite  hand  of  the  surgeon.     The  test  of  reduc- 

'  New  York  Journ.  of  Med.,  1857. 


COLLES'   FRACTUKE.  281 

tion  is  to  be  found  in  the  presence  of  the  head  of  the  ulna  on  the 
radial  side  of  the  ulnar  extensor. 

In  order  to  retain  the  ulna  in  place  when  reduction  is  effected,  Dr. 
Moore  places  a  thick,  firm  compress  over  its  lower  end,  on  the  palmar 
and  ulnar  margins  of  the  forearm ;  and  secures  this  in  place  with 
a  broad  band  of  adhesive  plaster  drawn  firmly  around  the  wrist.  The 
forearm  is  then  placed  in  a  narrow  sling  passing  under  the  wrist  and 
compress.     This  completes  the  dressing.^ 

In  the  first  volume  of  the  Philadelphia  Medical  Examiner  (1838) 
will  be  found  a  description  by  J.  Ehea  Barton,  of  Philadelphia,  of  a 
form  of  fracture  occurring  through  the  lower  end  of  the  radius,  which 
is  probably  much  less  common  than  CoUes'  fracture,  and  which  had 
hitherto  escaped  the  notice  of  surgeons.  Its  peculiarity  consists  in 
the  line  of  fracture  extending  very  obliquely  from  the  articulation, 
upwards  and  backwards,  separating  and  displacing  the  whole  or  only 
a  portion,  as  the  case  may  be,  of  the  posterior  margin  of  the  articu- 
lating surface.  I  have  not  recognized  this  fracture  in  any  instance 
which  has  come  under  my  own  observation,  nor  have  I  been  able  to 
find  a  cabinet  specimen  in  any  pathological  collection.  Dr.  Barton 
was  not  able  to  prove  the  correctness  of  his  diagnosis  by  an  autopsy, 
and  the  only  well-authenticated  example  which  I  can  find  upon  record 
is  that  to  which  Malgaigne  has  alluded,  as  having  been  seen  by  M. 
Lenoir,  and  of  which  an  account  was  published  in  the  Archives  Oene- 
rales  de  Medecine  in  183^.  M.  Lenoir  believed  it  to  be  a  simple 
luxation  of  the  hand  ba^wards,  but  the  patient  having  died,  he  was 
able  to  correct  his  diagnosis  by  an  autopsy.  A  considerable  fragment 
had  been  broken  from  the  posterior  lip  of  the  articular  surface,  the 
line  of  fracture  being  from  below  upwards,  and  from  before  back- 
wards. This  fragment  had  become  displaced  upwards  and  backwards, 
carrying  with  it  the  carpal  bones,  and  producing  thus  the  appearance 
of  a  simple  dislocation.^  I  believe  that  the  accident  so  carefully  de- 
scribed by  Barton  was  either  a  Colles'  fracture,  or  a  fracture  simply 
of  the  radial  margin,  of  which  I  have  given  two  supposed  examples, 
with  the  usual  signs  of  which  his  account  so  exactly  coincides,  and 
that  it  was  not  a  fracture  of  the  posterior  lip  of  the  articulating 
surface,  as  he  believed. 

Ninety-two  examples  of  fracture  of  the  lower  third  of  the  radius 
have  furnished  no  cases  of  non-union,  nor  indeed  do  I  remember  ever 
to  have  seen  the  union  delayed ;  yet  only  twenty-six  are  positively 
known  to  have  left  no  perceptible  deformity  or  stiffness  about  the 
joint:  it  is  probable,  however,  that  the  number  of  perfect  results 
might  be  somewhat  extended.  In  one  example,  the  case  of  a  man 
whose  arm  was  broken  in  Germany,  when  he  was  only  ten  years  old, 
the  fragments  of  the  radius  were  driven  into  each  other,  or  overlapped 
one  inch,  and  the  ulna  had  been  displaced  downwards  toward  the 
fingers  the  same  distance.  This  was  examined  twelve  years  after  the 
accident,  and  he  had  then  a  very  useful  arm.     Twice  I  have  found 

'  Moore,  New  York  Med.  Rec,  April  1,  1870. 

2  Malgaigne,  Traite  des  Frac,  etc.,  torn.  ii.  p.  700. 

19 


282  FEACTURES    OF    THE    RADIUS. 

the  wrist  and  finger-joints  quite  stiff  after  a  lapse  of  one  year;  in  one 
case  I  have  found  the  same  condition  after  two  years ;  in  one  case 
after  three  years,  and  in  two  cases  after  five  years. 

If  we  confine  our  remarks  to  Colles'  fracture,  the  deformity  which 
has  been  observed  most  often  consists  in  a  projection  of  the  lower 
end  of  the  ulna  inwards  and  generally  a  little  forwards.  In  a  large 
majority  of  cases  this  is  accompanied  with  a  perceptible  falling  of  the 
hand  to  the  radial  side,  while  in  a  few  it  is  not.  After  this,  in  point 
of  frequency,  I  have  met  with  the  backward  inclination  of  the  lower 
fragment.  Kobert  Smith  found  this  displacement  almost  constant  in 
the  cabinet  specimens  examined  by  him  ;  and  it  is  very  probable  that 
nearly  all  of  the  examples  examined  by  myself  would  present  more 
or  less  of  the  same  deviation  upon  the  naked  bone;  but  in  the  living 
examples  a  slight  deviation  would  be  concealed  by  the  numerous 
tendons  which  cover  this  part  of  the  arm,  and  perhaps  by  some  per- 
manent effusions,  of  which  I  shall  speak  more  particularly  presently. 

There  remains  for  a  long  time,  in  a  majority  of  cases,  a  broad,  firm, 
uniform  swelling  on  the  palmar  surface  of  the  forearm,  commencing 
near  the  upper  margin  of  the  annular  ligament  and  extending  upwards 
two  inches  or  more.  This  swelling  continues  much  longer  in  old  and 
feeble  persons  than  in  the  young  and  vigorous.  It  is  pretty  generally 
proportioned  to  the  amount  of  anchylosis  existing  at  the  wrist  and 
finger-joints,  and  it  disappears  usually  pari  2)assu,  with  these  condi- 
tions. There  can  be  no  doubt  that  this  pl^nomenon  is  due  to  effu- 
sions along  the  sheaths  of  the  tendons,  Mid  in  the  areolar  tissue 
external  to  the  sheaths,  and  it  is  as  often  present  after  sprains  and 
other  severe  injuries  about  this  part,  as  in  fractures.  In  many  cases, 
however,  its  prolonged  continuance  and  its  firmness  have  led  to  a  sus- 
picion that  the  bones  were  displaced,  a  suspicion  which  onl}^  a  mode- 
rate degree  of  care  in  the  examination  ought  easily  to  dispel.  A 
similar  effusion,  but  in  less  amount,  is  frequently  seen  also  on  the 
back  of  the  hand,  below  the  annular  ligament.  When  both  exist 
simultaneously  the  appearances  of  deformity  and  of  displacement  are 
greatly  increased.  Here,  then,  we  shall  find  a  partial  explanation  of 
the  anchylosis  in  the  wrist  and  finger-joints,  which  continues  occa- 
sionally many  months,  or  even  years,  if,  indeed,  it  is  not  permanent. 
An  anchylosis  produced  in  a  few  instances  by  extension  of  the  inflam- 
mation to  these  joints,  but  much  more  often  by  the  inflammatory 
effusion  and  consequent  adhesions  along  the  thecae  and  serous  sheaths, 
through  which  the  tendons  all  pass  in  their  course  to  the  hands  and 
fingers;  and  also  by  simple  contraction  of  the  articular  ligaments,  as 
a  consequence  of  disuse,  or,  as  it  is  usually  termed,  by  passive  con- 
traction of  these  ligaments.  The  fingers  are  quite  as  often  thus  an- 
chylosed  after  this  fracture  as  the  wrist-joint  .itself;  a  circumstance 
which  is  wholly  inexplicable  on  the  doctrine  that  the  anchylosis  is 
due  to  an  inflammation  in  the  joints.  Indeed,  I  have  seen  the  fingers 
rigid  after  many  months,  when,  having  observed  the  case  throughout 
myself,  I  was  certain  that  no  inflammatory  action  had  ever  reached 
them. 

Nor  is  it  any  more  difficult  to  show,  I  think,  that  the  anchylosis  of 


COLLES'    FKACTUEE.  283 

the  wrist-joint  is  not  often  due  to  a  malposition  of  its  articular  surfaces; 
as  has  frequently  been  asserted  in  the  written  treatises. 

The  most  superficial  examination  of  the  mechanism  of  this  joint 
ought  to  satisfy  us,  that  any  moderate  or  even  considerable  malposi- 
tion of  the  lower  fragment  after  a  fracture  of  the  radius,  is  not  suflBcient 
in  itself  to  occasion  anchylosis.  It  is  true  that  in  the  fracture  now 
under  consideration,  the  direction  of  the  articular  surface  of  the  radius 
is  changed,  and  that,  while  it  was  directed  downwards,  forwards,  and 
to  the  ulnar  side,  it  is  now,  perhaps,  directed  downwards,  backwards, 
and  to  the  radial  side.  But  of  what  consequence  is  this  so  long  as  the 
carpal  bones,  with  which  alone  this  bone  is  articulated,  preserve  their 
relations  to  the  radius  unchanged  ? 

If  any  other  evidence  be  demanded,  it  may  be  supplied  by  the 
experience  of  most  surgeons  in  examples  of  anchylosis  without  dis- 
placement ;  in  examples  of  displacement  without  anchylosis,  but  in 
which  the  anchylosis  has  yielded  gradually  to  the  lapse  of  time,  while 
the  displacement  has  continued.  The  following  case  is  in  point: 
James  Kyan,  a  private  in  the  15th  N.  Y.  volunteers,  fell  from  a  height 
into  a  ditch  during  the  battle  of  Fair  Oaks,  Ya.,  May  31, 1862,  striking 
npon  the  palm  of  his  left  hand,  and  causing  a  simple  fracture  near  the 
lower  end  of  the  radius,  accompanied  probably  with  impaction.  I  do 
not  know  what  treatment  was  adopted,  but  when  he  came  under  my 
observation  in  March,  1863,  at  the  Central  Park  General  Hospital, 
New  York,  I  found  the  most  extraordinary  deflection  of  the  hand  to 
the  radial  side  which  I  have  ever  seen  after  this  fracture.  The  hand 
could  be  turned  laterally,  to  a  right  angle  with  the  arm  ;  yet  the 
motions  of  flexion  and  extension  at  the  wrist-joint  were  nearly  as  per- 
fect as  in  the  opposite  arm,  and  the  hand  was  in  all  respects  as  useful 
as  before  the  accident. 

To  what  I  have  said  as  to  the  prognosis  in  these  accidents,  I  may 
be  permitted  to  add  the  opinion  of  our  distinguished  countryman, 
Dr.  Mott,  given  in  a  clinical  lecture  before  his  class  in  the  University 
of  New  York. 

"  Fractures  of  the  radius  within  two  inches  of  the  wrist,  where 
treated  by  the  most  eminent  surgeons,  are  of  very  difficult  manage- 
ment so  as  to  avoid  all  deformity ;  indeed,  more  or  less  deformity  may 
occur  under  the  treatment  of  the  most  eminent  surgeons,  and  more  or 
less  imperfection  in  the  motion  of  the  wrist  or  radius  is  very  apt  to 
follow  for  a  longer  or  shorter  time.  Even  when  the  fracture  is  well 
cured,  an  anterior  prominence  at  the  wrist,  or  near  it,  will  sometimes 
result  from  swelling  of  the  soft  parts." 

To  which  the  reporter,  himself  a  surgeon  in  the  city  of  New  York, 
adds : — 

"As  the  above  opinion  of  Professor  Mott  coincides  with  my  own 
observations,  both  in  Europe  and  in  this  city,  as  well  as  with  many  of 
our  most  distinguished  surgical  authorities,  I  venture  to  hope  that  it 
may  assist  in  removing  some  of  the  groundless  and  ill-merited  asper- 
sions which  are  occasionally  thrown  on  the  members  of  our  profession 
by  the  ignorant  or  designing."^ 

1  Boston  Med.  and  Surg.  Journal,  vol.  xxv.  p.  289. 


284  FRACTUEES  OF  THE  RADIUS. 

Of  gangrene  as  an  occasional  result  of  this  fracture,  I  shall  speak 
presently,  in  connection  with  the  subject  of  treatment. 

The  peculiar  character  of  the  displacement  which  characterizes 
Colles'  fracture,  and  the  constant  difficulty  experienced  by  surgeons 
in  obviating  deformity,  have  led  to  much  speculation  and  ingenious 
invention  ;  and  modern  surgeons,  especially,  have  thought  it  necessary 
to  introduce  here  an  essential  modification  of  the  usual  apparel  for 
broken  forearms.  This  modification  consists  in  employing  a  pistol- 
shaped  splint,  instead  of  a  straight  splint,  by  means  of  which  the  hand 
may  be  thrown  more  or  less  strongly  to  the  ulnar  side. 

Heister^  speaks  of  inclining  the  hand  toward  the  ulna,  while  re- 
ducing a  fracture  of  the  radius,  but  when  the  reduction  has  been 
effected  he  recommends  a  straight  splint. 

Among  the  first  to  advocate  the  permanent  confinement  of  the  band 
in  this  position,  were  Mr.  Cline,^  and  M.  Dupuytren.^  Mr.  Cline,  and 
after  him  Bransby  Cooper,^  and  Mr.  South,*  recommend  the  ordinary 
straight  splints  for  the  forearm,  but  the  rollers  by  which  the  splints 
are  secured  in  place  are  not  permitted  to  extend  lower  than  the  wrist; 
so  that  when  the  forearm  is  suspended  in  a  sling,  in  a  state  of  semi- 
pronation,  the  hand  shall  fall  by  its  own  weight  to  the  ulnar  side. 

Dupuytren,  and  after  him,  Chelius,  adopt,  in  addition  to  the  palmar 
and  dorsal  splints,  the  "  attelle  cubitale,"  or  ulnar  splint;  which  is  a 
gutter,  composed  of  steel,  iron,  tin,  or  some  other  metal,  and  made  to 
fit  the  ulnar  margin  of  the  forearm  and  hand,  when  the  hand  is  drawn 
forcibly  to  the  ulnar  side.  Blandin,^  Nelaton,^  and  Goyraud,*  also, 
under  certain  contingencies  employ  the  same. 

Most  surgeons,  however,  employ  either  a  palmar  or  a  dorsal  splint; 
or  both  palmar  and  dorsal  splints  constructed  with  a  knee,  or  pistol- 
shaped,  and  they  thus  avoid  the  necessity  of  the  ulnar  splint.  Thus, 
N^laton,^  Robert  Smith,^^and  Erichsen,"  recommend  this  peculiar  form 
only  in  the  dorsal  splint;  while  Bond,'^  Hays,'^  E.  P.  Smith,'''  G-.  F. 
Shrady,^'*  and  others,  especially  among  the  Americans,  place  the  pistol- 
shaped  splint  against  the  palmar  surface  of  the  forearm  and  hand. 

A  few  modern  surgeons  have  not  seen  fit  to  adopt  this  peculiar 
principle  of  treatment,  or  this  form  of  dressing  under  any  of  its  modi- 
fications. Colles^®  recommends  a  straight  palmar  and  dorsal  splint, and 
does  not  incline  the  hand.  Barton^^  advises  the  same,  and  Skey,  having 
declared  his  preference  for  a  couple  of  broad,  straight  splints,  adds: 
•' Great  care  should  be  taken  to  prevent  the  hand  falling,  and  this 

'  De  Lavrentii  Heisteri,  Institutiones  Cliirurgicse,  pars  prima,  p.  303,  Amsterdam 
iHl.,  1739. 

^  Malgaigne,  Traite  de  Frac,  etc.,  torn.  i.  p.  614,  Paris  ed. 

^  Dupuytren  on  Bones,  London  ed.,  p.  140. 

*  B.  Cooper,  Lectures  on  Surg.,  p.  232,  Amer.  ed. 

5  Chelius's  Surg.,  vol.  i.  p.  613.  ''  Malgaigne,  op.  cit.,  torn.  i.  p.  614. 

-  Nelaton,  Elem.  de  Path.  Cliir.,  tom.  i.  p.  747.  «  Ibid.,  p.  746. 

s  Nelaton,  op.  cit.,  p.  747.  '"  R.  Smith,  op.  cit.,  p.  168, 

"  Erichsen,  Sursrery,  p.  215. 

«  Bond,  Amer.  Journ.  Med.  Sci.,  April,  1852.  "  ibid.,  Jan.  1853. 

"  E.  P.  Smith,  Buffalo  Med.  Journ.,  vol.  ix.  p.  225. 

'5  Shrady,  Am.  Med.  Times,  2  cases,  Dec.  22,  1860. 

"^  Colles,  Lectures  on  Surgery,  p.  325.  "  Barton,  Phil.  Med.  Exam.,  1838. 


COLLES'   FRACTUEE. 


285 


object  will  be  attained  by  inclosing  the  entire  forearm  and  hand  in  a 
well-applied  sling."^ 


Fig.  89. 


Nelaton's  splint  for  fracture  of  the  radius. 

Fia;.  90. 


Hay's  splint. 

Professor  Fauger,  of  Copenhagen,  has  undertaken  to  treat  this  frac- 
ture in  some  sense  without  any  splint,  the  forearm  and  hand  being 
simply  laid  over  a  double-inclined  plane,  so  as  to  bring  the  wrist  into 
a  state  of  forced  flexion.  "  The  hand  having  been  brought  into  a  posi- 
tion of  strong  flexion,  the  forearm  is  placed,  pronated,  on  an  oblique 
plane,  with  the  carpus  highest,  the  hand  being  permitted  to  hang  freely 
down  the  perpendicular  end  of  the  plane.""  M.  Velpeau,  in  a  report 
of  his  surgical  clinic  at  La  Charite  for  the  year  ending  September, 
1846,  says  this  plan  has  been  tried  during  the  year,  and  "the  result 

'  Skey,  Operative  Surgery,  p.  161. 

2  Fauger,  London  Lancet,  May  8,  1847. 


286 


FEACTURES    OF    THE    EADIUS. 


has  not  been  very  satisfactory.     The  experiment,  however,  has  not 
been  decisive  upon  this  mode  of  treatment."^ 


Fiar.  92. 


E.  P.  Smith's  splint.     Surface  applied  to  forearm.     A.  Forearm  piece,  made  of  felt,  with  incurvated 
margins. 


Fig.  93. 


C  - 


E.  P.  Smith's  splint.  B.  Opposite  surface.  D,  the  hand-block,  is  connected  with  the  forearm  piece  by 
two  circular  brass  plates,  which  move  upon  eacli  other,  in  order  that  the  hand-block  may  assume  any- 
desired  angle  with  the  arm.  In  this  way  it  may  be  adapted  to  either  the  riglit  or  left  arm  It  is  fixed 
by  a  nut  seen  on  the  brass  plate.   The  letters  C  C  indicate  the  extent  of  motion  allowed  to  the  hand-block. 

Fiff.  94. 


Geo.  F.  Shrady's  splint.  To  be  applied  to  the  palmar  surface  of  forearm  and  hand  ;  the  hand  being 
deflected  towards  the  ulna.  A  strip  of  adhesive  plaster  encircles  the  forearm  and  splint  near  the  elbow, 
A  loop  is  also  formed  for  the  ulnar  margin  of  the  wrist  by  passing  one  end  of  a  strip  of  plaster,  3  inches 
in  width,  between  the  palmar  surface  of  the  wrist  and  the  splint,  over  on  the  dorsum  of  the  wrist  ;  both 
ends  being  then  brought  around  and  made  adherent  to  the  under  surface  of  the  splint.  Lastly,  the  hand 
is  secured  to  the  hand-piece  by  a  circle  of  plaster  ;  the  dorsal  splint,  if  required,  can  then  be  applied  in 
the  usual  way.  Passive  motion  is  made  every  second  or  third  day,  by  grasping  the  apparatus  at  wrist 
and  freeing  the  hand. 

Notwithstanding  these  exceptions,  the  practice  seems  to  be  pretty 
well  established  among  the  leading  surgeons  everywhere  to  employ 
in  the  treatment  of  this  fracture  the  principle  of  adduction  of  the 
hand,  and  always  to  the  attainment  of  the  same  purpose,  namely, 
rotary  extension,  by  which  they  hope  to  retain  more  securely  the 
lower  fragment  in  place, 

•  Velpeau,  Boston  Med.  Journ.,  vol.  xxxv.  p.  213. 


COLLES'   FRACTURE.  287 

We  corae  now  to  consider  how  far  this  peculiar  treatment  is  capa- 
ble of  answering  the  special  indications  of  the  case  we  are  studying. 

It  is  assumed,  as  I  have  already  intimated,  that,  by  bearing  the  hand, 
strongly  to  the  ulnar  side,  the  fragments  of  the  radius  are  brought 
more  exactly  into  apposition,  and  more  easily  and  effectually  retained; 
an  assumption  which  supposes  two  things  to  have  been  determined: 
first,  that  there  exists  an  overlapping  of  the  fragments,  either  through 
the  whole  extent  of  their  broken  surfaces  or  especially  toward  the 
radial  side,  or  that  the  upper  end  of  the  lower  fragment  is  inclined  to 
fall  against  the  ulna,  or  that  all  of  these  several  conditions  coexist ; 
and,  secondly,  that  if  such  displacements  do  exist,  they  can  be  reme- 
died by  this  manoeuvre. 

The  first  of  these  suppositions  seems  to  have  been  sufficiently  con- 
sidered by  all  those  gentlemen  who  have  particularly  examined  the 
specimens  contained  in  the  various  pathological  collections,  and  to 
who.se  careful  investigations  I  have  already  frequently  adverted.  With 
rare  exceptions,  none  of  these  displacements  have  been  found  to  exist, 
although,  as  has  been  observed,  a  casual  inspection  of  the  arm  when 
recently  broken  would  often  lead  to  an  opposite  conclusion.  I  do  not 
here  speak  of  impaction,  which  is  usually  upon  the  posterior  margin, 
if  it  exists  at  all. 

In  regard  to  the  second  supposition,  namely,  that  where  such  dis- 
placements do  exist,  a  forced  adduction  will  aid  in  the  retention  of 
the  fragments,  I  shall  have  to  speak  more  cautiously,  because,  so  far 
as  I  know,  my  opinions  have  received  as  yet  no  public  and  authorita- 
tive indorsement.  In  order  that  adduction  may  prove  effective,  there 
must  be  some  point  upon  which  to  act  as  a  fulcrum.  It  is  of  no  use  that 
we  rotate  the  hand  for  the  purpose  of  making  extension  unless  there 
can  be  found  a  resistance  or  fulcrum  upon  which  the  rotary  motion 
may  be  performed.  Such  a  fulcrum  exists,  no  doubt,  but  to  deter- 
mine its  availability  we  must  ascertain  its  character  and  position. 

It  is  not  in  the  lower  end  of  the  ulna,  for  the  ulna  has  no  point  of 
contact  with  the  carpal  bones,  and  when,  in  the  natural  state  of  these 
parts,  the  hand  is  inclined  to  the  ulnar  side,  the  lower  end  of  the  ulna, 
rides  freely  downwards  upon  the  wrist  until  arrested  by  the  ligaments 
which  unite  it  with  the  carpus,  or  by  the  capacity  of  the  joint  to  admit 
of  motion  in  this  direction.  When  the  lower  end  of  the  radius  is 
broken,  and  the  ligaments  of  the  joint  are  more  or  less  torn,  the  ulna 
although  thrust  downwards  much  farther  perhaps  than  it  could  ever 
descend  in  its  normal  state,  still  fails  to  find  a  support,  and  spreading 
wider  and  wider  from  the  radius  as  it  is  thrust  farther  upon  the  hand, 
no  limit  can  be  given  to  its  progress  in  this  direction.  It  was  thus 
that,  in  one  example  already  mentioned,  I  found  the  ulna  carried 
downwards  one  inch  or  more. 

The  resistance  will,  then,  in  nearly  all  cases,  be  found  to  be  in  those 
ligaments  which  bind  the  lower  fragment  to  the  lower  end  of  the  ulna, 
and  the  ulna  to  the  carpal  bones,  viz.,  the  radio-ulnar,  and  the  internal 
lateral  ligaments,  which  in  the  normal  state  of  the  parts  constitute  the 
centre  upon  which  forced  adduction  expends  its  power,  and  which 
still  continue  to  be  the  point  of  resistance  when  the  radius  is  broken. 


288  FKACTURES    OF    THE    RADIUS. 

But  how  feeble  and  uncertain  must  be  a  resistance  which  depends 
solely  on  these  injured  ligaments!  And  how  painful  to  the  patient 
must  be  an  extension  sufficient  to  overcome  the  action  of  nearly  all 
the  muscles  of  the  wrist,  which  is  borne  entirely  by  a  few  lacerated 
and  inflamed  fibres  !  even  in  health  this  position,  when  forced,  cannot 
be  endured  beyond  a  few  seconds,  and  it  must  be  difficult  to  estimate 
the  sufferings  which  the  same  position  must  occasion  when  the  liga- 
ments are  torn  and  inflamed. 

I  am  not  to  be  told  that  surgeons  have  not  intended  to  advocate  this 
extreme  practice ;  that  they  have  never  recommended  forced  adduc- 
tion, but  only  a  moderate  and  easy  lateral  inclination,  such  as  can  be 
comfortably  borne.  If  they  have  not,  then  they  should  not  have 
spoken  of  making  extension  by  this  means.  An  easy  lateral  inclina- 
tion has  no  power  to  do  good  so  far  as  extension  is  concerned,  any 
more  than  it  has  power  to  do  harm.  But  the  fact  is,  while  a  majority 
of  surgeons  have  no  doubt  used  less  force  than  was  hurtful,  some  have 
used  more  than  was  useful  or  safe;  indeed,  the  sharpness  of  the  curve 
given  to  the  splints  figured  and  recommended  by  Dupuytren,  Nelaton, 
and  others,  sufficiently  indicates  that  their  distinguished  inventors  in- 
tended to  accomplish  by  these  means  a  forced  and  violent  adduction. 
Malgaigne,  speaking  of  other  means  of  extension  applied  to  the 
forearm,  suggested  by  Godin.Diday,  and  Velpeau,  intended  to  operate 
only  in  a  straight  line,  and,  alluding  especially  to  the  modes  devised 
by  Huguier  and  Velpeau,  remarks:  "Without  discussing  here  the 
comparative  value  of  the  two  forms  of  apparatus,  I  believe  that  they 
could  scarcely  be  endured  by  the  patients ;  and  M.  Diday  tells  us  that 
in  the  trials  which  he  has  made,  the  pain  produced  by  the  extension 
was  so  great  that  he  was  compelled  to  renounce  it."  Which  observa- 
tions cannot  but  apply  equally  to  this  plan  of  extension  by  adduction 
or  to  any  other  which  might  be  adopted. 

After  all,  it  must  not  be  inferred  that  I  have  concluded  to  reject 
this  mode  of  dressing  in  all  of  its  modifications  ;  for  although  I  am  far 
from  being  persuaded  of  its  utility  as  a  means  of  extension  and  re- 
tention in  any  case,  yet  I  am  not  prepared  to  deny  to  it  some  very 
considerable  value  in  another  point  of  view;  and  when  judiciously 
employed  it  can  certainly  do  no  harm.  It  is,  I  repeat,  for  another 
reason  altogether  than  the  one  heretofore  assigned,  that  I  would  re- 
commend its  continuance,  a  reason  which  I  cannot  so  well  explain,  or 
hope  to  render  intelligible,  except  to  the  practical  surgeon.  This 
position  throws  the  whole  lower  end  of  both  radius  and  ulna  outwards 
toward  the  radial  margin  of  the  splints,  and  by  keeping  the  radius 
more  completely  in  view,  it  enables  the  surgeon  better  to  judge  of  the 
accuracy  of  the  reduction,  and  to  recognize  more  readily  the  condition 
and  situation  of  the  compresses,  etc.  This  alone  I  have  always  con- 
sidered a  sufficient  ground  for  retaining  the  angular  splint;  although 
I  have  treated  a  great  number  of  arms  satisfactorily  with  the  straight 
splints  alone. 

Finally,  while  surgeons  have  been  seeking  to  accomplish  an  indica- 


COLLES'   FRACTURE.  289 

tion,  the  existence  of  which  is  at  least  rendered  doubtful,  and  by 
means  which  appear  to  me  totally  inadequate,  if  it  did  exist,  they  have 
probably  too  often  overlooked  or  regarded  indifferently  an  indication 
which  is  almost  uniformly  present,  namely,  to  press  forwards  the  tilted 
fragment  by  a  force  applied  upon  the  wrist  from  behind,  and  to  retain 
it  in  place  by  suitable  compresses.  And  I  cannot  help  thinking  that 
if  they  had  regarded  this  as  the  sole  indication,  an  indication  gene- 
rally so  easily  accomplished,  they  would  have  made  fewer  crooked 
arms,  and  have  saved  their  patients  much  suffering  and  themselves 
much  trouble.  Some  of  the  cases  which  I  have  reported  in  the  early 
part  of  this  chapter,  are  intended  to  illustrate  the  value  of  this  principle. 

In  case  the  ulna  is  dislocated  also,  and  is  imprisoned  by  the  annular 
ligament,  circumduction  with  extension,  as  practised  by  Dr.  Moore, 
and  heretofore  described,  will  be  required. 

It  only  remains  for  us  to  determine  the  precise  form  of  splint  which 
ought  to  be  preferred,  and  to  describe  its  mode  of  application. 

The  narrow  "attelle  cubitale"  of  Dupuytren  is  inconvenient;  nor 
can  I  give  the  preference  to  the  curved  dorsal  splint  recommended  by 
N^latou,  and  employed  by  Robert  Smith,  Erichsen,  and  others.  It  is 
not  to  me  a  matter  of  entire  indifference,  in  case  only  one  curved  splint 
is  employed,  whether  this  be  applied  to  the  palmar  or  dorsal  surfaces 
of  the  forearm.  Foreign  surgeons,  so  far  as  I  know,  have  applied  this 
splint  to  the  dorsal  surface,  and  the  straight  splint  to  the  palmar; 
while  American  surgeons  have  adopted  almost  as  uniformly  the  oppo- 
site rule — to  whose  practice,  in  this  respect,  I  acknowledge  myself 
also  partial.  It  is  to  the  curved  splint  rather  than  to  the  straight,  that 
we  mainly  trust;  not  simply,  or  at  all,  perhaps,  because  of  its  form, 
but  because  the  curved  splint  is  also  the  long  splint.  This  is  the 
splint,  therefore,  which  ought  to  be  the  most  steady  and  immovable 
in  its  position.  Now,  the  very  irregularities  of  surface  upon  the 
palmar  aspect  of  the  forearm  and  hand,  instead  of  constituting  an 
embarrassment,  enable  us,  when  the  splint  is  suitably  prepared  and 
adjusted,  to  fix  it  more  securely.  Moreover,  upon  it  alone,  after  a 
few  days,  the  surgeon  may  see  fit  to  rely,  and  in  that  case  it  ought  to 
be  applied  to  that  surface  of  the  arm  which  is  most  tolerant  of  con- 
tinued pressure.  The  palmar  surface,  as  being  more  muscular,  and 
as  having  been  more  accustomed  to  friction  and  to  pressure,  must 
necessarily  have  the  advantage  in  this  respect.  The  palmar  splint  ter- 
minating also  at  the  metacarpo-phalangeal  articulations,  instead  of  at 
the  wrist,  as  the  short  straight  splint  must  do  when  the  hand  is  ad- 
ducted,  enables  the  hand  to  be  flexed  upon  its  extremity  over  a  hand- 
block,  or  pad  of  proper  size.  Such  are  the  not  insignificant  advantages 
which  we  claim  for  this  mode  over  that  pursued  by  our  transatlantic 
brethren. 

The  block  suggested  first  by  Bond,  of  Philadelphia,  is  a  valuable 
addition,  since  the  flexed  position  is  always  more  easy  for  the  fingers, 
and  in  case  of  anchylosis  this  position  renders  the  whole  hand  more 
useful. 

For  myself,  I  am  in  the  habit  of  preparing  extemporaneously  a 


290  FRACTURES    OF    THE    RADIUS. 

splint  from  a  wooden  shingle,  which  I  first  cut  into  the  requisite  shape 
and  length,  the  length  being  obtained  by  measuring  from  the  front 
of  the  elbow-joint,  when  the  arm  is  flexed  to  a  right  angle,  to  the 
metacarpo-phalangeal  articulations.  It  ought,  indeed,  to  fall  half  an 
inch  short  of  the  bend  of  the  elbow,  to  render  it  certain  that  it  shall 
make  no  uncomfortable  pressure  at  this  point;  and  the  direction  to 
measure  with  the  arm  flexed  is  of  sufficient  importance  to  warrant  a 

repetition.     The  breadth  of  the  splint 
Fig.  95.  should  be  in  all  its  extent  just  equal 

to  the  breadth  of  the  forearm  in  its 
widest  part,  so  that  there  shall  be  no 
lateral  pressure  upon  the  bones.  If 
the  splint  is  of  unequal  breadth,  the 
roller  cannot  be  so  neatly  applied,  and 
The  author's  splint.  it  IS  morc  Hkcly  to  become  disarranged. 

Thus  constructed,  it  is  to  be  covered 
with  a  sack  of  cotton  cloth,  made  to  fit  tightly,  with  the  seam  along 
its  back,  and  afterwards  stuffed  with  cotton  batting  or  with  curled 
hair.  These  materials  may  be  passed  in,  and  easily  adjusted,  wherever 
they  are  most  needed,  from  the  open  extremities  of  the  sack.  While 
preparing,  the  splint  must  be  occasionally  applied  to  the  arm  until  it 
fits  accurately  every  part  of  the  forearm  and  hand,  only  that  the  stuff- 
ing must  be  rather  more  firm  a  little  above  the  lower  end  of  the  upper 
fragment.  The  open  ends  of  the  sack  are  then  to  be  neatly  stitched 
over  the  ends  of  the  splint,  after  which  the  splint  may  be  laid  directly 
upon  the  skin  without  any  intermediate  compresses  or  rollers. 

The  advantages  of  this  form  of  splint  are  easily  comprehended. 
They  consist  in  facility  and  cheapness  of  construction,  accuracy  of 
adaptation,  neatness,  permanency,  and  fitness  to  the  ends  proposed. 

The  extemporaneous  splint  recommended  by  Dr.  Isaac  Hays,  of 
Philadelphia,  is  very  similar,  but  it  lacks  the  neatness  and  perma- 
nency of  that  which  I  have  now  described. 

In  all  cases  it  is  better  to  employ,  also,  at  least  during  the  first 
fortnight,  a  straight  dorsal  splint,  of  the  same  breadth  as  the  palmar 
splint,  and  of  sufficient  length  to  extend  from  the  elbow  to  the  middle 
of  the  carpus.  This  should  be  covered  and  stuffed  in  the  same  man- 
ner as  the  palmar  splint,  except  that  here  the  thickest  and  firmest 
part  of  the  splint  must  be  opposite  the  carpus  and  the  lower  end  of 
the  lower  fragment.  It  will  answer  the  indications  also  a  little  more 
completely  if,  at  this  point,  the  padding  is  thicker  on  the  radial  than 
on  the  ulnar  side. 

Having  restored  the  fragment  to  place,  in  case  of  Colles'  fracture, 
by  pressing  forcibly  upon  the  back  of  the  lower  fragment,  the  force 
being  applied  near  the  styloid  apophysis  of  the  radius,  the  arm  is  to 
be  flexed  upon  the  body,  and  placed  in  a  position  of  semi-pronation, 
when  the  splints  are  to  be  applied,  and  secured  with  a  sufficient  num- 
ber of  turns  of  the  roller,  taking  especial  care  not  to  include  the 
thumb,  the  forcible  confinement  of  which  is  always  painful  and  never 
useful. 


FRACTUEES  OF  THE  RADIUS. 


291 


I  cannot  too  severely  reprobate  Fig.  96. 

the  practice  of  violent  extension 
of  the  wrist  in  the  efforts  at  re- 
duction when  no  overlapping  of 
the  fragments  exists  and  the  ulna 
is  not  dislocated,  and  that,  whether 
this  extension  be  applied  in  a 
straight  line,  or  with  the  hand 
adducted.  It  has  been  shown 
that  in  a  great  majority  of  cases 
no  indication  in  this  direction  is 
to  be  accomplished,  and  to  pull 
violently  under  these  circum- 
stances upon  the  wrist  is  not  only 
useless  but  hurtful.  It  is  adding 
to  the  fracture,  and  to  the  other 
injuries  already  received,  the 
graver  pathological  lesion  of  a 
stretching,  a  sprain  of  all  the  lig- 
aments connected  with  the  joint. 
I  am  persuaded  that  to  this  vio- 
lence, added  to  the  unequal  and 
too  firm  pressure  of  the  splints, 
are,  in  a  great  measure,  to  be  at- 
tributed the  subsequent  inflamma- 
tion and  anchylosis  in  very  many 
cases. 

The  first  application  of  the  bandages  ought  to  be  only  moderately 
tight,  and  as  the  inflammation  and  swelling  develop  in  these  struc- 
tures with  rapidity  the  bandages  should  be  attentively  watched,  and 
loosened  as  soon  as  they  become  painful.  It  must  be  constantly  borne 
in  mind  that,  to  prevent  and  control  inflammation,  in  this  fracture,  is 
the  most  difficult  and  by  far  the  most  important  object  to  be  accom- 
plished, while  to  retain  the  fragments  in  place,  when  once  reduced,  is 
comparatively  easy. 

During  the  first  seven  or  ten  days,  therefore,  these  cases  demand 
the  most  assiduous  attention;  and  we  had  much  better  dispense  with 
the  splints  entirely  than  to  retain  them  at  the  risk  of  increasing  the 
inflammatory  action.  Indeed,  I  have  no  doubt  that  very  many  cases 
would  come  to  a  successful  termination  without  splints,  if  only  the 
hand  and  arm  were  kept  perfectly  still  in  a  suitable  position  until 
bony  union  was  effected. 

I  must  also  enter  my  protest  against  many  or  all  of  those  carved 
splints  which  are  manufactured,  hawked  about  the  country,  and  sold 
by  mechanics,  who  are  not  surgeons;  with  a  fossa  for  each  styloid 
process,  a  ridge  to  press  between  the  bones,  and  various  other  curious 
provisions  for  supposed  necessities,  but  which  never  find  in  any  arm 
their  exact  counterparts,  and  only  deceive  the  inexperienced  surgeon 
into  neglect  of  the  proper  means  for  making  a  suitable  adaptation. 


The  author's  dressing  complete.  The  curved 
palmar  splint  is  not  in  view,  only  the  dorsal.  The 
faint  white  lines  represent  the  roller.  The  -ling 
is  omitted  for  the  purpose  of  bringing  the  other 
dressings  into  view. 


292  FRACTURES    OF    THE    RADIUS. 

They  are  the  fruitful  sources  of  excoriations,  ulcerations,  inflamma- 
tions, and  deformities. 

In  reference  to  the  treatment  of  these  fractures,  the  following  cases 
and  the  accompanying  remarks,  by  that  great  surgeon,  Dupuytren,  are 
too  pertinent  not  to  merit  a  place  in  every  treatise  of  this  character. 

"The  two  succeeding  cases  are  not  only  interesting  as  fractures  of 
the  radius,  but  they  are  farther  deserving  of  attentive  consideration, 
on  account  of  the  serious  complications  which  accompanied  them,  and 
which  were  the  consequence  of  forgetting  an  important  precept.  More 
than  once,  indeed,  it  has  occurred  tliat  the  surgeons  have  been  so  in- 
tent on  preserving  fractures  in  their  proper  position  that  the  extreme 
constriction  employed  has  actually  caused  destruction  of  the  soft  parts. 
A  piece  of  advice  which  I  have  very  frequently  given,  and  which  I 
cannot  too  often  repeat,  is  to  avoid  tightening  too  much  the  apparatus 
for  fractures  during  the  first  few  days  of  its  being  worn  ;  for  the  swell- 
ing which  supervenes  is  always  accompanied  by  considerable  pain, 
and  may  be  followed  by  gangrene.  It  cannot,  therefore,  be  too  ur- 
gently impressed  on  young  practitioners,  to  pay  attention  to  the  com- 
plaints which  patients  make;  and  to  visit  them  twice  daily,  and  relax 
the  bandages  and  straps  as  need  may  be,  in  order  to  obviate  the 
frightful  consequences  which  may  spring  from  not  heeding  this  neces- 
sary precaution ;  by  carefully  attending  to  this  point  I  have  been 
saved  the  painful  alternative  of  ever. having  to  sacrifice  a  limb  for 
complications  which  its  neglect  may  entail. 

"  Antoine  Eilard,  a^t.  44,  fractured  his  right  radius  whilst  going 
down  into  a  cellar,  in  Feb.  1828,  and  went  at  once  to  the  Hospital  of 
La  Charit^.  When  the  fracture  was  reduced  (it  was  near  the  base  of 
the  bone)  an  apparatus  was  applied,  but  fastened  too  tightly;  and, 
notwithstanding  the  great  swelling  and  the  acute  pain  which  the 
patient  endured,  it  was  not  removed  until  the  fourth  day,  when  the 
hand  was  cold  and  oedematous,  and  the  forearm  red,  painful,  and 
covered  with  vesications.  Leeches,  poultices,  and  fomentations  were 
applied,  and  followed  by  some  alleviation  of  the  local  symptoms, 
though  there  was  much  constitutional  disturbance.  At  the  close  of  a 
fortnight  from  the  accident,  the  palmar  surface  of  the  forearm  pre- 
sented a  point  where  fluctuation  was  supposed  to  exist;  but  when  a 
bistoury  was  plunged  into  it  no  matter  followed.  Portions  of  the 
flexor  muscles  subsequently  sloughed,  and  the  skin  subsequently 
mortified.  The  only  resource  was  amputation,  which  was  performed 
above  the  elbow  six  weeks  after  his  admission ;  and  he  afterwards 
recovered  without  the  occurrence  of  any  further  untoward  symptoms. 

"R.,  set.  36,  was  at  work  boring  an  artesian  well  in  1832,  when  he 
was  struck  by  part  of  the  machinery  on  the  right  forearm ;  he  was 
instantly  knocked  down  and  thrown  violently  on  the  right  thigh.  A 
surgeon  who  was  sent  for  detected  a  fracture  of  the  radius,  and  ap- 
plied the  usual  apparatus,  consisting  of  pads  and  splints,  confined  by 
a  roller  extending  from  the  extremities  of  the  fingers  to  the  elbow, 
which  compressed  the  arm  so  tightly  as  to  give  rise  to  very  great 
suffering.  The  fingers,  hand,  and  forearm  were  numbed  almost'  to 
insensibility,  and  yet  the  surgeon  in  attendance  did  not  think  proper 


FEACTURES  OF  THE  RADIUS.  293 

to  loosen  the  apparatus.  Such  was  the  condition  of  the  patient  until 
he  came  to  the  Hotel  Dieu,  four  days  after  the  accident;  the  fingers 
were  then  black,  cold,  and  insensible,  and  when  I  removed  the  splints 
I  found  the  hand  likewise  black,  especially  on  its  palmar  surface. 
The  lower  part  of  the  forearm  was  a  shade  less  livid,  but  equally  cold 
and  insensible;  and  several  vesicles  filled  with  pink-colored  serum 
were  apparent  on  both  its  surfaces  where  the  splints  had  pressed  ;  the 
upper  part  of  the  forearm  was  inflamed,  swollen,  and  very  painful. 
He  was  bled  and  leeches  were  applied  to  the  inflamed  part  of  the  arm  ; 
camphorated  spirit  was  applied  to  the  fingers. 

"  On  the  following  day  heat  was  restored  as  low  as  the  wrist,  but 
the  hand  remained  for  the  most  part  livid  and  cold,  and  the  radial 
artery  did  not  pulsate.  Seventy  leeches  were  applied  to  the  forearm, 
and  the  local  application  was  continued."  On  the  second  day  after 
admission  thirty  more  leeches  were  applied.  On  the  fourth  day  the 
hand  looked  a  little  better,  so  as  to  ''encourage  some  hope  of  its  being 
saved ;  but  this  was  again  blighted  on  the  sixth  day,  by  the  entire  loss 
of  heat  and  sensibility  in  the  part  and  increased  pain  and  swelling  in 
the  forearm,  to  which  the  gangrene  subsequently  extended.  On  the 
twelfth  day  amputation  was  performed  at  the  elbow-joint;  but  the 
patient  did  not  survive  the  operation  more  than  ten  days,  the  imme- 
diate cause  of  death  being  acute  pleurisy.  There  was  a  considerable 
quantity  of  purulent  serosity  poured  out  on  the  right  side  of  the  chest ; 
and  abscesses  were  found  in  the  lungs  and  liver.  On  examining  the 
arm,  there  was  found  to  be  a  simple  fracture  of  the  radius  about  its 
centre. 

"  The  above  case  presents  a  painful  illustration  of  the  neglect  to 
which  I  have  alluded.  In  nearly  every  instance  the  swelling  of  the 
limb  requires  that  careful  attention  should  be  paid  to  the  bandage  or 
straps,  by  which  the  apparatus  is  confined.  Similar  accidents  are 
likely  to  result  from  the  employment  of  an  immovable  apparatus,  of 
which  an  example  occurred  in  the  practice  of  M.  Thierry,  one  of  my 
pupils.  He  was  summoned  to  visit  a  young  girl,  on  whom  such  an 
apparatus  had  been  applied  for  supposed  fracture  of  the  radius. 
After  suffering  excruciating  torment,  the  forearm  mortified,  and  am- 
putation was  the  only  resource;  on  examining  the  limb  no  trace  of 
fracture  could  be  discovered.  Had  a  simple  apparatus  been  here  em- 
ployed, and  properly  watched,  this  patient's  limb  would  not  have  been 
sacrificed."^ 

Eobert  Smith  mentions,  also,  the  case  of  a  boy,  set.  18,  who  had  a 
fracture  of  the  lower  extremity  of  the  radius,  through  the  line  of  the 
junction  of  the  epiphysis  with  the  diaphysis,  caused  by  being  thrown 
from  a  horse.  A  surgeon  applied,  within  an  hour,  a  narrow  roller 
tightly  around  the  wrist.  On  the  following  day  the  limb  was  in- 
tensely painful,  cold  and  discolored  ;  still  the  roller  was  not  removed, 
nor  even  slackened.  On  the  fourth  day  he  was  admitted  into  the 
Kichmond  Hospital,  when  the  gangrene  had  reached  the  forearm. 
Spontaneous  separation  of  the  soft  parts  finally  occurred,  and  the 

'  Dupuytren,  Injuries  and  Diseases  of  Bones,  Syd.  ed.,  Loudon,  1847,  pp.  145-7. 


294-  FRACTUEES    OF    THE    RADIUS. 

bones  were  sawn  through  twenty-four  days  after  the  fracture  was 
produced,  from  which  time  "everything  proceeded  favorably,'" 

Nov.  21,  1851,  a  boy,  ten  years  old,  living  in  the  town  of  Andover, 
Mass.,  had  his  left  hand  drawn  into  the  picker  of  a  woollen  mill,  pro- 
ducing several  severe  wounds  of  the  hand  and  a  fracture  of  the  radius 
near  its  middle.  One  of  the  wounds  was  situated  directly  over  the 
point  of  fracture,  but  whether  it  communicated  with  the  bone  or  not 
was  not  ascertained.  A  surgeon  was  called,  who  closed  the  wounds, 
covered  the  forearm  with  a  bandage  from  the  hand  to  above  the  elbow, 
and  applied  compresses  and  splints.  This  lad  made  no  complaint,  his 
appetite  remaining  good  and  his  sleep  continuing  undisturbed,  until 
the  third  day,  when  he  began  to  speak  of  a  pain  in  his  shoulder ;  on 
the  same  day  also  it  was  noticed  that  his  hand  was  rather  insensible  to 
the  prick  of  a  pin.  Early  on  the  morning  of  the  fourth  day  his  sur- 
geon being  summoned,  found  him  suffering  more  pain  and  quite  rest- 
less ;  and  on  removing  the  dressings,  the  arm  was  discovered  to  be 
insensible  and  actually  mortified  from  the  shoulder  downwards. 

Opiates  and  cordials  were  immediately  given  to  sustain  the  patient, 
and  fomentations  ordered. 

On  the  sixth  day  a  line  of  demarcation  commenced  across  the  shoul- 
der, and  on  the  twenty-first  day  the  father  himself  removed  the  arm 
from  the  body  by  merely  separating  the  dead  tissues  with  a  feather. 
Subsequently  a  surgeon  found  the  head  of  the  humerus  remaining  in 
the  socket,  and  removed  it,  the  epiphysis  having  become  separated 
from  the  diaphysis.     The  boy  now  rapidly  got  well. 

In  the  year  1853  this  case  became  the  subject  of  a  legal  investiga- 
tion, in  the  course  of  which  Dr.  Pilsbury,  of  Lowell,  Mass.,  declared 
that  in  his  opinion  this  unfortunate  result  had  been  caused  by  too 
tight  bandaging,  and  by  neglecting  to  examine  the  arm  during  four 
days. 

On  the  other  hand,  Drs.  Hay  ward,  Bigelow,  Townsend,  and  A  ins- 
worth,  of  Boston,  with  Kimball,  of  Lowell,  Drs.  Loring  and  Pierce, 
of  Salem,  believed  that  the  death  of  the  limb  was  due  to  some  injury 
done  to  the  artery  near  the  shoulder-joint;  and  in  no  other  way  could 
they  explain  the  total  absence  of  pain  during  the  first  two  days;  nor 
could  they  regard  this  condition  as  consistent  with  the  supposition 
that  the  bandage  occasioned  the  death  of  the  limb.^ 

I  cannot  but  think,  however,  that  these  gentlemen  were  mistaken, 
and  that  the  gangrene  was  alone  due  to  the  bandages.  In  a  similar 
case  which  came  under  my  own  observation,  and  in  which  both  the 
radius  and  ulna  were  broken,  the  roller  extended  no  higher  than  just 
above  the  elbow,  and  the  patient  complained  of  no  pain  until  the 
bandages  were  unloosed,  yet  the  arm  separated  at  the  shoulder-joint. 
I  shall  refer  again  to  this  example  in  the  chapter  on  fractures  of  the 
radius  and  ulna ;  and  I  shall  take  occasion  then  also  to  S23eak  more 
fully  of  the  causes  of  these  terrible  accidents. 

Norris  mentions  another  case  of  compound  fracture  of  the  lower 

•  R.  Smith,  Treatise  on  Fractures,  &c.,  Dublin,  1854,  p.  170. 
2  Bost.  Med.  and  Surg.  Journ.,  vol.  xlviii.  p.  281. 


FRACTURES    OF    THE    RADIUS,  295 

end  of  the  radius  which  came  under  his  notice  at  the  Pennsylvania 
Hospital  in  August,  1837,  the  arm  having  been  dressed  by  a  surgeon 
within  half  an  hour  after  the  accident,  with  bandages  and  splints. 
When  these  bandages  were  removed  at  the  hospital,  on  the  fifth  day, 
"the  soft  parts  around  the  fracture  were  found  to  have  sloughed,  an 
abscess  extended  up  to  the  elbow-joint,  and  sloughs  existed  over  the 
condyle.  Several  constitutional  symptoms  arose,  making  amputation 
of  the  arm  necessary.'" 

A  lady,  ^t.  50,  was  also  seen  by  Thierry,  who,  having  broken  the 
radius  near  its  lower  end,  lost  her  fingers  by  the  sloughing  consequent 
upon  a  tight  bandage.^ 

A  woman  was  admitted  into  one  of  Dr.  Wood's  wards  in  the  Belle- 
vue  Hospital  about  the  first  of  February,  1863,  who  had  fallen  upon 
her  hand  a  few  days  before  and  broken  the  radius  just  above  the 
wrist.  Her  arm  was  dressed  with  splints  and  bandages  at  one  of  the 
dispensaries  in  this  city.  Gangrene  ensued,  and  when  I  saw  her  on 
the  8th  of  February,  the  death  had  extended  to  the  middle  of  the  fore- 
arm; the  dead  tissues  being  dry  and  black.  Dr.  Wood  amputated  the 
arm,  but  she  died. 

The  remarks  which  have  now  been  made  in  relation  to  the  treatment 
of  Colles'  fracture,  are  applicable,  with  only  such  slight  modifications 
as  would  naturally  be  suggested,  to  fractures  of  the  lower  end  of  the 
radius  commencing  upon  the  radial  side  of  the  bone  and  extending 
obliquely  downwards  into  the  joint;  and  it  is  to  this  form  of  fracture 
especially,  that  the  pistol-shaped  splint  must  be  found  applicable.  If 
the  fracture  actually  extends  into  the  joint,  it  must  not  be  forgotten 
that,  in  order  to  the  prevention  of  anchylosis,  the  wrist  should  be 
early  subjected  to  passive  motion. 

The  following  example  of  a  compound  comminuted  fracture  of  the 
radius  may  serve  to  illustrate  the  value  of  a  somewhat  novel  mode 
of  treatment  under  certain  circumstances: — 

William  Croak,  of  Buffalo,  aet.  30.  January  29,  1856,  a  large  piece 
of  iron  casting  fell  upon  his  arm,  crushing  and  lacerating  the  wrist, 
and  comminuting  the  lower  part  of  the  radius;  he  was  immediately 
taken  to  the  Hospital  of  the  Sisters  of  Charity,  I  found  the  whole  of 
the  soft  parts  torn  away  in  front  of  the  joint,  and  the  fragments  of  the 
radius  projected  into  the  flesh  in  every  direction.  The  hope  of  saving 
the  hand  seemed  to  be  scarcely  sufficient  to  warrant  the  attempt ;  at 
least  by  the  ordinary  mode  of  procedure.  I,  however,  stated  to  the 
gentlemen  present,  among  whom  were  Dr.  Rochester,  my  colleague, 
and  the  house  surgeon,  Dr.  Lemon,  that  I  believed  it  could  be  saved 
if,  having  removed  the  fragments  of  the  radius,  we  practised  resection 
of  the  lower  end  of  the  ulna,  and  allowed  the  muscles  to  become  com- 
pletely relaxed.  Accordingly,  after  placing  my  patient  under  the 
influence  of  chloroform,  I  enlarged  the  wounds  so  as  to  enable  me  to 
remove  six  or  seven  frao-ments  of  the  radius,  leavino-  others  which 
were  broken  off  but  not  much  displaced,     I  then  removed  with  the 

'  Norris,  note  to  Liston's  Surgery,  p.  54. 

2  Amer.  Journ.  Med.  ScL,  vol.  xxv.  p.  461,  from  L'Experience  for  1838. 


296 


FEACTURES    OF    THE    RADIUS. 


saw  one  inch  and  a  half  of  the  lower  end  of  the  ulna.  The  hand  was 
immediately  drawn  up  by  the  contraction  of  the  remaining  muscles, 
but  their  tension  was  completely  relieved. 

The  wounds  were  closed  and  dressed  lightly,  and  the  whole  limb 
was  placed  on  a  broad  and  well-padded  splint  covered  with  oiled  cloth. 
The  hand,  which  was  very  pale  and   exsanguine,  was 
Fig.  97.        covered  with  warm  cotton  batting. 

The  subsequent  treatment  was  changed  from  time  to 
time  to  suit  the  indications;  but  his  recovery  was  rapid 
and  complete,  nor  was  there  at  any  time  excessive  inflam- 
mation in  any  part  of  the  limb. 

I  have  seen  this  man  frequently  since  he  left  the  hospi- 
tal, and  while  he  has  recovered  only  a  little  motion  in  the 
/  wrist-joint,  his  hand  and  fingers  are  nearly  as  useful  as 

before  the  accident.  He  is  able  to  perform  all  ordinary 
kinds  of  labor  with  almost  as  much  ease  as  most  other 
men;  and  what  is  always  gratifying  to  the  humane  sur- 
geon, he  does  not  fail  to  appreciate  fully  the  service  which 
has  been  conferred  upon  him  by  the  preservation  of  his 
somewhat  mutilated  hand. 

I  have  recently  adopted  the  same  treatment  with  equal 
success  in  a  case  of  gunshot  wound  of  the  lower  end  of 
the  radius. 

Epiphyseal  Sepiarations. — This  bone  is  formed  from 
three  centres,  namely,  one  for  the  shaft  and  one  for  either 
extremity.  The  shaft  is  ossified  at  birth.  About  the  end 
of  the  second  year  ossification  commences  in  the  lower 
epiphysis,  and  it  becomes  united  to  the  shaft  at  about  the 
twentieth  year.  The  same  process  commences  in  the 
upper  epiphysis  at  about  the  fifth  year,  and  is  completed 
by  consolidation  with  the  shaft  at  the  age  of  puberty. 
I  have  met  with  no  recorded  examples  of  separation  of  the  upper 
epiphysis,  and  the  examples  of  separation  of  the  lower  epiphysis  have 
seldom  been  clearly  made  out.  I  have  already  mentioned  one  as 
having  been  reported  by  Robert  Smith.  He  speaks  also  of  other 
cases  occurring  in  conjunction  with  a  separation  of  the  lower  end  of 
the  ulna,  and  which  is  very  liable  to  be  mistaken  for  a  dislocation.* 

The  treatment  of  this  accident  will  not  require  any  special  con- 
sideration, since  it  will  not  diflfer  essentially  from  the  treatment  re- 
quired in  a  fracture  occurring  at  the  same  point. 


'  Robert  Smith,  op.  cit.,  p.  164. 


SHAFT    OF    THE    ULNA. 


297 


CHAPTEH    XXII 


FRACTURES  OF  THE  ULNA. 


§  1.  Shaft  of  the  Ulna. 

Causes. — The  shaft  of  the  ulna,  when  it  alone  is  the  seat  of  fracture, 
is  generally  broken  by  a  direct  blow.  I  have  never  seen  an  excep- 
tion to  this  rule;  "but  Voisin  has  related  in  the  Gazette  Mtdicale  for 
1833  a  single  exception,  in  which  it  was  said  to  have  been  broken  by 
a  fall  upon  the  palm  of  the  hand.  Malgaigne  thinks  it  is  most  often 
broken  when  one  seeks  to  ward  off  a  blow  with  the  arm  ;  but  it  has 
happened  most  often  to  me  to  see  it  broken  by  a  fall  upon  the  side  of 
the  arm. 

Point  of  Fracture,  Direction  of  Displacement,  &c. — In  an  analysis 
of  thirty-three  cases,  I  find  the  shaft  has  been  broken  eleven  times  in 
its  upper  third,  twelve  times  in  its  middle  third,  and  ten 
times  in  its  lower  third.     All  portions  seem,  therefore.         Fig.  98. 
to  be  about  equally  liable  to  fracture.     I  think,  also,  the 
fractures  have  generally  been  oblique. 

Contrary  to  what  has  been  observed  by  other  writers, 
I  have  noticed  that  no  law  prevailed  as  to  the  direction 
in  which  the  fragments  have  become  displaced  ;  the 
broken  ends  being  found  directed  forwards,  backwards, 
inwards,  or  outwards,  according  to  the  direction  of  the 
blow  which  has  occasioned  the  fracture ;  and  this  is  in 
accordance  with  the  general  rule  in  other  fractures 
occasioned  by  direct  blows.  No  doubt,  however,  other 
things  being  equal,  the  tendency  of  the  lower  fragment 
would  be  toward  the  interosseous  space,  in  consequence 
of  the  action  of  the  pronator  quadratus  in  this  direction, 
while  the  upper  fragment,  owing  to  its  broad  and  firm 
articulation  at  the  elbow-joint,  can  only  be  displaced 
forwards  or  backwards,  at  least  to  any  great  extent. 

Complications. — In  no  case  of  the  shaft  of  a  long  bone 
have  I  found  serious  complications  more  frequent  than 
in  fractures  of  the  shaft  of  the  ulna.     Four  have  been 
compound ;  eleven  complicated  with  a  forward,  or  for- 
ward and  outward  dislocation  of  the  head  of  the  radius ;       Fracture  of  the 
one  with  a  partial  dislocation  of  the  lower  end  of  the    shaft  of  the  uina. 
radius  backwards,  and  one  with  a  dislocation  of  both 
radius  and  ulna  backwards  at  the  elbow-joint.     It  will  be  seen,  there- 
fore, that  sixteen,  or  nearly  one-half  of  the  whole  number,  have  been 
seriously  complicated. 

Symxjtoms. — Occasionally  this  fracture  is  found  to  exist  without 
sensible  displacement.     In  such  cases  the  diagnosis  is  sometimes  diffi- 
20 


298  FEACTUEES    OF    THE    ULNA. 

cult,  and  can  only  be  determined  by  the  crepitus  and  mobility.  IP 
however,  the  ulna  is  firmly  seized  above  and  below  the  point  which 
has  suffered  contusion,  and  pressed  in  opposite  directions,  these  signs 
will  generally  be  sufficiently  manifest,  and  will  render  the  diagnosis 
certain. 

But  in  cases  where  there  is  considerable  displacement,  the  inner 
surface  of  the  bone  is  so  superficial  as  to  enable  us  to  detect  its  devia- 
tions with  the  eye  alone,  or,  when  swelling  has  already  occurred,  by 
the  fingers  carried  firmly  and  slowly  along  this  margin. 

If  the  head  of  the  radius  is  dislocated  also,  the  displacement  of  the 
broken  ends  of  the  ulna  must  always  be  considerable,  and  the  con- 
sequent deformity  palpable.  I  have  known  one  instance,  however, 
in  which  a  surgeon  living  in  the  neighboring  Province  of  Upper 
Canada  recognized  and  reduced  a  dislocation  of  the  radius  and  ulna 
backwards,  but  did  not  detect  a  fracture  of  the  ulna  two  inches  above 
its  lower  end.  Six  months  after,  in  the  month  of  March,  1856,  the 
patient  called  upon  me  with  a  marked  deformity  near  the  wrist,  oc- 
casioned by  the  backward  projection  of  the  broken  ulna,  and  with  a 
complete  loss  of  the  power  of  supination.  It  will  not  surprise  us  that 
this  fracture  was  overlooked  when  we  learn  that  the  man  had  fallen 
fifty-five  feet. 

Prognosis. — In  simple  fractures  the  prognosis  is  generally  favorable, 
since  no  overlapping  can  occur,  and  the  lateral  displacements  are  not 
usually  sufficient  to  produce  a  marked  deformity,  or  to  interfere 
materially  with  the  functions  of  the  arm  ;  yet  it  is  not  unfrequent  to 
find  the  fragments  inclining  slightly  forwards  or  backwards,  inwards 
or  outwards.  If  the  fragments  fall  toward  the  radius,  I  have  noticed 
in  three  or  four  instances  a  slight  projection  of  the  lower  end  or  sty- 
loid process  of  the  ulna  to  the  ulnar  side;  but  not  interfering  in  any 
degree  with  the  motions  of  the  wrist-joint. 

I  have  seen  the  radius  left  unreduced  seven  times  after  a  fracture  of 
the  ulna,  and  in  each  example  the  forearm  was  shortened.  A  boy,  ast. 
17,  was  struck  by  a  locomotive,  and  severely  injured  in  various  parts 
of  his  body,  June  5,  1855.  I  saw  him  with  two  very  intelligent  coun- 
try practitioners,  a  few  hours  after  the  accident.  The  whole  left  arm 
was  then  greatly  swollen.  Crepitus  was  distinct,  and  we  easily  recog- 
nized the  fracture  of  the  ulna  about  three  inches  below  its  upper  end, 
with  which  an  open  wound  was  in  direct  communication.  We  sus- 
pected, also,  a  dislocation  of  the  head  of  the  radius  forwards,  but  as  we 
could  not  make  ourselves  certain,  and  finding  that  the  arm  was  in 
such  a  condition  as  to  preclude  any  further  manipulation  without 
greatly  diminishing  the  chance  of  saving  the  limb,  we  made  no  attempt 
at  reduction,  but  laid  the  arm  upon  a  pillow  and  directed  cool  water 
lotions. 

At  no  subsequent-  period,  in  the  opinion  of  the  medical  gentleman 
who  was  left  in  charge,  did  a  favorable  opportunity  occur  to  reduce 
the  radius;  and  at  the  end  of  two  months  I  found  the  ulna  united, 
with  the  fragments  bent  forwards  and  outwards  toward  the  radius, 
while  the  head  of  the  radius  lay  in  front  of  the  humerus.     The  forearm 


SHAFT    OF    THE    ULNA.  299 

was  shortened  tbree-quarters  of  an  inch.  He  could  flex  his  arm  freely 
to  a  right  angle  and  a  little  beyond ;  and  he  could  straighten  it  per- 
fectly. Hand  slightly  pronated,  with  partial  loss  of  supination.  Whole 
arm  nearly  as  strong  and  as  useful  as  before  the  accident. 

The  second  case  occurred  in  the  person  of  a  man  ast.  26,  residing 
about  twenty  miles  from  town,  and  was  occasioned  by  the  kick  of  a 
horse.  This  was  also  a  compound  fracture.  It  does  not  appear  that 
his  surgeon  discovered  the  dislocation  of  the  radius,  but  supposed  that 
it  was  a  fracture  of  both  bones.  On  the  ninth  day  the  patient  became 
dissatisfied  and  dismissed  his  surgeon,  but  employed  no  other. 

Oct.  1,  1849,  eleven  weeks  after  the  accident,  he  called  upon  me.  I 
found  the  ulna  united  with  a  manifest  displacement,  but  I  could  not 
discover  that  there  had  been  any  fracture  of  the  radius.  The  head 
of  the  radius  was  in  front  of  the  external  condyle,  and  a  depression 
existed  where  it  formerly  articulated.  When  the  arm  was  flexed,  the 
head  did  not  strike  the  humerus  so  as  to  arrest  the  flexion,  but  it 
glided  upwards  and  outwards  along  the  inclined  base  of  the  external 
condyle.  He  had  already  begun  to  use  his  arm  considerably  in  labor. 
The  forearm  was  shortened  one  inch. 

Three  times  I  have  noticed  after  the  lapse  of  several  years  that  the 
forearm  could  not  be  perfectly  supinated ;  but  pronation  was  never 
permanently  impaired.  I  think,  also,  that  the  motions  of  flexion  and 
extension  have  always,  except  where  the  radius  has  remained  dislo- 
cated, been  completely  restored  soon  after  the  splints  were  removed ; 
and  even  in  these  latter  cases,  it  is  only  extreme  flexion  which  has 
been  hindered. 

Treatment. — In  simple  fracture  we  must  look  carefully  to  the  lateral 
deviation  of  the  fragments;  and  if  they  are  found  to  be  salient  forwards 
or  backwards,  pressure  made  directly  upon  or  near  their  extremities, 
restores  them  to  place,  but  it  often  requires  considerable  force  to  ac- 
complish this.  A  gentleman  fell  and  broke  the  right  ulna  near  its 
middle.  He  came  immediately  to  me,  and  I  found  the  fragments  dis- 
placed backwards.  Pressing  strongly  with  my  fingers,  they  sprung 
forwards  with  a  distinct  crepitus,  and  I  thought  they  were  now  in 
exact  line.  A  broad  and  well-padded  splint  was  applied  to  the  fore- 
arm, and  I  took  especial  pains  with  compresses  nicely  adjusted,  from 
day  to  day,  to  keep  everything  in  place.  The  arm  was  placed  in  a 
sling.  Eight  months  after  the  accident  this  gentleman  died  of  cholera, 
and  I  was  permitted  to  dissect  the  arm.  I  found  the  fragments  well 
united,  but  with  a  very  palpable  projection  of  the  fragments  back- 
wards, in  the  direction  in  which  they  were  at  first. 

If  the  displacement  is  in  the  direction  of  the  radius,  it  is  more  diffi- 
cult to  overcome,  but  its  necessity  is  much  more  urgent,  since,  if  the 
fragments  fall  completely  against  the  radius,  a  bony  union  may  take 
place,  occasioning  a  complete  loss  of  the  power  of  pronation  and  of 
supination 

While  moderate  extension  is  being  made,  and  the  hand  is  well 
supinated,  the  fingers  of  the  surgeon  should  be  pressed  firmly,  and  in 
spite  sometimes  of  the  complaints  of  the  patient,  between  the  radius 


800  FEACTUEES    OF    THE    ULKA. 

and  ulna,  and  the  fragments  of  the  broken  ulna  fairly  pushed  out  from 
the  radius. 

The  forearm  may  now  be  laid  in  the  usual  position  against  the  front 
of  the  chest,  midway  between  supination  and  pronation,  and  the  same 
splints  applied  and  in  the  manner  which  we  shall  hereafter  describe 
for  fractures  of  the  shaft  of  both  bones. 

We  ought,  however,  especially  to  bear  in  mind  the  danger  of  thrust- 
ing the  fragments  against  the  radius,  b}'-  allowing  the  sling  or  the 
bandage  to  rest  against  the  middle  of  the  ulnar  side  of  the  bone.  To 
prevent  this,  the  sling  ought  to  support  the  arm  by  passing  only  under 
the  hand  and  wrist,  or  the  forearm  may  be  laid  in  a  firm  gutter  which 
will  touch  the  forearm  only  at  the  elbow  and  wrist,  or  it  may  be  laid 
upon  its  back  as  suggested  and  practised  by  Scott,  and  also  by  Fleury, 
the  latter  of  whom,  according  to  Malgaigne,  had  a  case  which  had 
been  treated  in  the  position  of  semi-pronation,  and  which  remained 
not  only  displaced,  but  refused  to  unite ;  but  when  the  arm  was  supi- 
nated,  the  fragments  came  at  once  into  contact  and  bony  union  speedily 
took  place.  This  position  may  be  adopted  whenever  it  is  found  to  be 
practicable;  but  the  position  of  semi-pronation  is  generally  much 
more  comfortable  to  the  patient,  at  least  when  the  forearm  is  laid 
across  the  chest,  and  I  have  found  very  few  patients  who  would  sub- 
mit to  a  position  of  complete  supination. 

In  fractures  accompanied  with  dislocation  of  the  head  of  the  radius 
forwards  or  backwards,  nothing  should  prevent  the  immediate  reduc- 
tion of  the  dislocation  but  a  demonstration  of  its  impossibility,  or  a 
condition  of  the  limb  which  would  render  manipulation  hazardous. 
It  can  be  reduced,  generally,  by  pushing  forcibly  upon  the  head  of  the 
bone  in  the  direction  of  the  socket,  while  the  arm  is  moderately  flexed 
so  as  to  relax  the  biceps,  and  while  extension  is  being  made  at  the 
forearm  by  an  assistant.  In  making  the  counter-extension,  care  should 
be  taken  to  seize  the  lower  end  of  the  humerus  by  the  condyles,  rather 
than  by  its  anterior  aspect,  by  which  precaution  we  shall  avoid  press- 
ing upon  and  rendering  tense  the  tendon  of  the  biceps. 

July  29,  1845,  a  lad,  set.  9,  fell  from  his  bed,  breaking  the  ulna 
and  dislocating  the  head  of  the  radius.  Dr.  Austin  Flint  was  called 
on  the  following  morning,  and  at  his  request  I  was  invited  to  see  the 
patient  with  him.  We  found  the  ulna  broken  obliquely  near  its  mid- 
dle, and  the  head  of  the  radius  dislocated  forwards.  While  Dr.  Flint 
seized  the  elbow  in  front  of  the  condyles,  I  made  extension  from  the 
hand,  the  forearm  being  slightly  flexed  upon  the  arm,  and  at  the  same 
moment  I  pushed  forcibly  the  head  of  the  radius  back  to  its  socket. 
The  reduction  was  accomplished  easily  and  completely. 

We  then  dressed  the  arm  with  an  angular  splint,  constructed  with 
a  joint  opposite  the  elbow.  This  was  laid  upon  the  palmar  surface, 
and  the  whole  was  nicely  padded,  especially  in  front  of  the  head  of 
the  radius.  In  two  weeks  pasteboard  was  substituted  for  the  angular 
splint.  At  the  end  of  six  weeks  I  was  permitted  to  examine  the  arm, 
and  found  the  head  of  the  radius  perfectly  in  place,  but  the  points  of 
fracture  slightly  salient.  All  of  the  motions  of  the  arm  were  fully 
restored. 


CORONOID    PROCESS    OF    THE    ULNA.  301 

June  2,  1845.  C.  C,  £et.  9,  fell  upon  his  arm,  breaking  the  ulna 
obliquely  near  its  middle,  and  dislocating  the  head  of  the  radius  for- 
wards. Dr.  J.  P.  White  being  called,  requested  me  to  visit  the  patient 
also  with  him.  We  found  one  of  the  broken  fragments  protruding 
through  the  skin,  on  the  inside  of  the  arm. 

With  great  ease,  and  by  simply  pressing  with  considerable  force 
upon  the  head  of  the  radius,  it  was  made  to  slide  into  its  socket.  The 
case  was  left  in  charge  of  Dr.  White. 

Five  weeks  after,  I  found  all  of  the  motions  of  the  forearm  com- 
pletely restored,  except  that  he  could  not  extend  it  perfectly.  The 
head  of  the  radius  was  also  a  little  more  prominent  in  front  than  in 
the  opposite  arm. 

Four  or  five  years  later,  the  projection  of  the  head  of  the  radius  had 
disappeared,  and  the  functions  of  the  arm  were  perfect. 


§  2.  CoRONOiD  Process  of  the  Ulna. 

Dissections  have  established  the  possibility  of  this  fracture  as  a 
simple  accident  in  the  living  subject ;  but  I  have  not  myself  seen  any 
example  of  which  I  can  speak  positively.  In  the  two  following  cases, 
the  existence  of  such  a  fracture  was  at  first  suspected,  but  I  have  now 
very  little  doubt  but  that  my  diagnosis  was  incorrect.  I  shall  relate 
them,  however,  as  examples  of  those  accidents  which  are  likely  to  be 
mistaken  for  fracture  of  this  process. 

A  laboring  man,  aged  about  twenty-five  years,  had  been  seen  and 
treated  by  another  surgeon,  for  what  was  supposed  to  be  a  simple 
dislocation  of  the  radius  and  ulna  backwards.  The  surgeon  thought 
he  had  reduced  the  dislocation  very  soon  after  the  accident.  On  the 
following  day  he  found  the  dislocation  reproduced,  and  he  requested 
me  to  see  the  patient  with  him.  The  arm  was  then  much  swollen, 
but  the  character  of  the  dislocation  was  apparent.  By  moderate  ex- 
tension, applied  while  the  arm  was  slightly  flexed,  and  continued  for 
a  few  seconds,  reduction  was  again  effected,  the  bones  returning  to 
their  places  with  a  distinct  sensation;  but  on  releasing  the  arm  the  dis- 
location was  immediately  reproduced.  These  attempts  to  reduce  and 
retain  in  place  the  dislocated  bones  were  repeated  several  times  during 
this  day,  and  on  subsequent  days,  but  to  no  purpose,  and  the  patient 
was  dismissed  after  about  two  weeks  with  the  bones  unreduced. 

The  impossibility  of  retaining  the  bones  in  place,  and  the  existence 
of  an  occasional  crepitus  during  the  manipulation,  inclined  me  to  be- 
lieve at  the  time  that  the  dislocation  was  accompanied  with  a  fracture 
of  the  coronoid  process. 

Another  similar  case  has  since  presented  itself  in  a  child  nine  years 
old,  and  in  which  the  subsequent  examinations  not  only  demonstrated 
the  non-existence  of  a  fracture,  but  also  rendered  doubtful  the  justness 
of  the  conclusions  which  I  had  drawn  in  the  case  just  related. 

This  lad  fell,  Nov.  4,  1855,  and  his  parents  immediately  brought 
him  to  me ;  but  as  he  lived  many  miles  from  town,  I  did  not  see  him 


302  FEACTUEES    OF    THE    ULNA. 

until  eighteen  hours  after  the  injury  was  received.  I  found  the  arm 
much  swollen,  slightly  flexed,  and  pronated.  Flexion  and  extension 
of  the  arm  were  very  painful,  the  pain  being  referred  chiefly  to  the 
front  of  the  joint,  near  the  situation  of  the  coronoid  process ;  and  at  this 

Fig.  99. 


Fracture  of  the  coronoid  process. 

point  also  there  was  a  discoloration  of  the  size  of  a  twenty -five  cent 
piece.  Flexing  the  forearm  moderately  upon  the  arm  and  making 
extension,  the  bones  came  readily  into  place,  but  without  sensation  of 
any  kind,  either  a  snap  or  a  crepitus.  That  the  bones  had  now  re- 
sumed their  position,  however,  I  made  certain  by  a  very  careful  exami- 
nation with  the  hand  and  by  measurement,  yet  they  would  not  remain 
in  place  one  moment  when  the  extension  was  discontinued.  The 
reduction  was  made  several  times,  and  constantly  with  the  same  result. 
We  then  applied  a  right-angled  splint  to  the  arm,  having  first  reduced 
the  bones,  and  thus  were  able  to  retain  them  in  position.  I  believed 
that  the  coronoid  process  was  broken,  and  so  informed  the  surgeon  to 
whose  care  the  boy  was  returned. 

Five  months  after,  he  was  brought  again  to  me,  and  I  then  found 
that  the  radius  and  ulna  had  been  kept  in  place ;  the  motions  of  the 
joint  were  perfect,  and  if  the  coronoid  process  had  ever  been  broken  it 
was  now  again  in  its  natural  position,  and  with  every  structure  about  it 
in  a  condition  as  complete  as  it  was  before  the  accident.  For  myself, 
I  do  not  believe  that  so  perfect  a  union  of  this  process  can  happen — 
at  least  in  a  case  where,  as  must  have  been  the  fact  in  this  example, 
the  separation  and  displacement  of  the  process  are  such  that  it  no 
longer  offers  an  obstacle  to  the  dislocation  of  the  ulna  backwards  and 
upwards. 

Malgaigne  thinks  that  the  fracture  is  more  frequent  than  the  small 
number  of  reported  examples  would  lead  us  to  suppose,  especially 
because  he  has  noticed  how  often  the  summit  of  the  process  is  broken 
off,  when  dislocation  of  the  radius  and  ulna  backwards  is  produced 
artificially  on  the  dead  subject.  In  three  or  four  cases,  also,  of  dis- 
locations of  these  bones  backwards  and  inwards,  which  had  come 
under  his  notice,  he  was  unable  to  feel  this  process,  and  he  therefore 
thought  it  probable  that  it  was  broken  off.  Other  surgeons  have 
thought,  also,  that  it  was  a  not  infrequent  accident;  and  they  have 
constantly  made  use  of  this  supposition  to  explain  those  cases  in 
which  the  radius  and  ulna  having  been  dislocated  backwards,  would 
not  afterward  remain  in  place  when  well  reduced.  Fergusson  has 
indeed  made  the  extraordinary  statement  in  relation  to  dislocations  of 
the  radius  and  ulna  backwards  generally,  that  in  these  cases  "  the 
coronoid  process  will  probably  be  broken." 

But,  in  my  opinion,  these  fractures  are  exceedingly  rare;  and  I  think 
these  gentlemen  need  to  have  furnished  some  more  conclusive  evi- 


CORONOID    PROCESS    OF    THE    ULNA.  803 

dence  of  the  correctness  of  their  opinions  than  can  be  found  in  their 
writings,  or  in  the  writings  of  any  other  surgeons  which  I  have  seen, 

Malgaigne  mentions  three  reported  examples,  namely:  one  pub- 
lished by  Combes  Brassard,  an  Italian  surgeon,  in  1811,  which  Bras- 
sard saw  only  after  a  lapse  of  three  months ;  one  seen  by  Pennock,  and 
published  in  the  Lancet  in  1828,  the  patient  then  being  sixty  years 
old,  and  the  accident  having  occurred  when  he  was  a  young  man  ;  the 
third  was  seen  by  Sir  Astley  Cooper,  several  months  after  the  accident, 
and  is  reported  by  himself  in  his  excellent  treatise  on  Fractures  and 
Dislocations.  Says  Mr.  Cooper  :  "  It  was  thought,  at  the  consultation 
which  was  held  about  him  in  London,  that  the  coronoid  process  was 
detached  from  the  ulna,"  This  was  the  only  living  example  seen  by 
Mr.  Cooper  in  his  long  and  immensely  varied  surgical  practice;  and 
even  here  we  cannot  fail  to  notice  the  apparent  reserve  with  which  he 
expresses  his  opinion — "It  was  thought  at  the  consultation." 

To  these  examples  our  own  researches  have  added  a  few  others. 

Dorsey  says  that  Dr.  Physick  once  saw  a  fracture  of  the  coronoid 
process.  The  symptoms  resembled  a  luxation  of  the  forearm  back- 
wards, "except  that  when  the  reduction  was  effected,  the  dislocation 
was  repeated,  and  by  careful  examination,  crepitation  was  discovered. 
The  forearm  was  kept  flexed  at  a  right  angle  with  the  humerus.  The 
tendency  of  the  brachieus  internus  to  draw  up  the  superior  fragm6nt 
was  counteracted  in  some  measure  by  the  pressure  of  the  roller  above 
the  elbow,  A  perfect  cure  was  readily  obtained."^  In  1830,  Dr.  Wm. 
M.  Fahnestock  reported  a  case  occurring  in  a  boy,  who,  having  fallen 
from  a  haymow,  received  the  whole  weight  of  his  body  "  on  the  back 
part  of  the  palm  of  the  left  hand,"  while  the  arm  was  extended  for- 
wards. It  seemed  to  be  a  dislocation  of  the  forearm  backwards,  but 
when  reduced  it  was  again  immediately  displaced,  with  an  evident 
crepitus.  The  arm  was  secured  in  the  angular  splint  of  Dr.  Physick 
and  "recovered  very  speedily,"^  Dr.  Coaper,  of  the  Glasgow  Infirm- 
ary, also  has  reported  a  dislocation  of  the  forearm  backwards  and  out- 
wards, occurring  in  a  young  man  aged  seventeen,  and  which  he  thinks 
was  accompanied  with  this  fracture.  The  dislocation  was  easily  re- 
duced, but  returned  again  immediately  on  ceasing  the  extention.  The 
fragment  was  not  felt,  nor  does  he  speak  of  crepitus ;  the  existence  of 
the  fracture  being  inferred  from  the  fact  that  the  bones  would  not 
remain  in  place  without  help.  The  forearm  was  placed  across  the 
chest,  with  the  fingers  pointing  toward  the  opposite  shoulder,  and 
secured  in  this  position  with  splints  and  a  bandage.  At  the  end  of 
four  weeks  union  had  taken  place,  with  only  slight  deformity,  although 
with  some  stiffness  of  the  joint. 

In  relation  to  this  example,  the  editor  remarks  that  the  symptoms 
were  not  to  his  mind  conclusive  in  determining  the  existence  of  a 
fracture  of  the  coronoid  process,  and  he  inclines  to  the  belief  that  it 
was  rather  an  oblique  fracture  of  the  lower  extremity  of  the  humerus. 
"  In  cases  like  these,"  he  adds,  "  where  very  rare  accidents  are  sus- 

•  Dorsey,  Elements  of  Surgery,  vol.  i.  p.  153.     Philadelphia,  1813. 
2  Fahnestock,  Amer.  Journ.  Med.  Sci.,  vol.  vi.  p.  207. 


804  FRACTUEES    OF    THE    ULNA. 

|Dected,  we  think  that  unless  the  diagnosis  is  clear,  the  leaning  should 
always  be  the  other  way  :  we  mean  that,  cseteris  jJccribus,  the  symptoms 
should  rather  be  referred  to  the  common  than  the  extraordinary 
injury.  The  contrary  practice  introduces  a  dangerous  laxity  in  diag- 
nosis."^ 

Dr.  Duer,  of  Philadelphia,  has  reported  a  case  which  occurred  in  a 
boy  six  years  old,  and  in  which  he  felt  and  moved  the  fragment  with 
his  fingers.  It  was  complicated  with  a  dislocation,  which  remains  un- 
reduced. This  case  was  last  seen  about  seven  weeks  after  the  accident.^ 
If  at  a  later  period  we  could  be  permitted  to  examine  the  patient,  it 
is  probable  that  the  diagnosis  might  be  rendered  certain. 

In  the  American  Medical  Monthly  for  October,  1855,  also,  I  find  the 
report  of  a  trial  for  malpractice,  in  which  a  lad  nine  years  old  re- 
ceived some  injury  about  the  elbow-joint  which  resulted  in  a  maiming. 
The  defendant  claimed  that  there  had  been  a  dislocation  of  the  fore- 
arm backwards,  accompanied  either  with  a  fracture  of  the  trochlea 
of  the  humerus,  or  of  the  coronoid  process  of  the  ulna. 

Dr.  Crosby,  of  Dartmouth  College,  testified  that  he  had  never  met 
with  a  fracture  of  this  process,  yet  he  would  not  say  that  it  did  not 
exist  in  this  case.  He  was  not  able  to  decide  positively.  Dr.  Peaslee, 
of  the  same  college,  thought  it  altogether  probable  that  it  had  been 
broken,  and  Dr.  Spaulding  was  of  the  opinion  fully  that  it  had  been 
broken. 

The  jury  did  not  agree,  and  a  nonsuit  was  finally  allowed  by  the  court. 

The  defendant,  in  his  report  of  the  trial,  seems  to  me  to  have  justly 
complained  that  Mr.  Fergusson  has  said,  that  in  a  dislocation  of  the 
forearm  backwards  "  the  coronoid  process  will  probably  be  broken," 
This  was  urged  in  the  trial  by  the  plaintiff's  counsel  as  contradicting 
the  medical  testimony,  and  as  evidence  of  a  conspiracy  on  the  part  of 
the  surgeons  to  defeat  the  ends  of  justice ;  since  they  constantly  affirmed 
that  the  accident  was  so  rare  as  not  to  have  been  reasonably  expected, 
and  that  a  failure  to  look  for  or  to  discover  it  did  not  imply  a  lack  of 
ordinary  skill  or  care.' 

Says  Mr.  Liston :  "The  coronoid  process  is  occasionally  pulled  or 
pushed  off  from  the  shaft,  more  especially  in  young  subjects.  I  saw 
a  case  of  it  lately,  in  which  the  injury  arose  in  consequence  of  the 
patient,  a  boy  of  eight  years,  having  hung  for  a  long  time  from  the 
top  of  a  wall  by  one  hand,  afraid  to  drop  down  ;"^  after  whom  Miller, 
Erichsen,  Skey,  Lonsdale,  and  most  of  the  Scotch  and  English  sur- 
geons have  repeated  the  assertion  that  this  process  may  be  broken  in 
this  manner  by  the  action  of  the  brachialis  anticus  alone,  yet  no  one 
of  them  has  to  this  day  seen  another  example. 

The  explanation  of  the  accident  in  the  case  of  the  boy,  given  by 
Liston,  implies  two  anatomical  errors:  first,  that  the  coronoid  process 
is  an  epiphysis  during  childhood;  and  second,  that  the  brachialis  anti- 
cus is  inserted  upon  its  summit.  The  coronoid  process  is  never  an  epi- 
physis, but  is  formed  from  a  common  point  of  ossification  with  the 

*  Couper,  Lond.  Med.-Chir  Rev.,  new  ser.,  vol.  xi,  p.  509. 

2  Duer,  Amer.  Journ.  Med.  Sci.,  Oct.  1863,  p.  390. 

3  Op.  cit.,  vol.  iv.  p.  839.  *  Liston,  Practical  Surgery,  p.  55. 


CORONOID    PROCESS    OF    THE    ULNA. 


305 


shaft ;  the  olecranon  process  and  the  lower  extremity  of  Fig.  lOO. 
the  ulna  having  also  separate  points  of  ossification :  the 
olecranon  becoming  united  to  the  shaft  at  the  sixteenth 
year,  and  the  lower  epiphysis  at  the  twentieth.  Moreover, 
the  brachialis  anticus  has  its  insertion  at  the  base  of  the 
process  and  partly  upon  the  body  of  the  ulna,  but  in  no 
part  upon  its  summit;  indeed,  the  process  seems  rather  to 
be  intended  as  a  pulley  over  which  the  brachialis  anticus 
may  play ;  resembling  also  somewhat,  in  its  function,  the 
patella ;  serving  to  protect  the  joint  and  perhaps  the  muscle 
itself  from  becoming  compressed  in  the  motions  of  the 
joint.  Certainly  it  could  never  have  been  broken  by  the 
action  of  this  muscle,  and  the  case  mentioned  by  Mr.  Liston 
must  find  some  other  explanation.  It  may  have  been  a 
rupture  of  the  brachialis  anticus  itself,  or  of  the  biceps, 
or  possibly  a  forward  luxation  of  the  head  of  the  radius. 
Either  of  these  suppositions  is  more  rational  than  the  state- 
ment made  by  Mr.  Liston,  because  either  one  of  them  is 
possible,  while  his  supposition  is  impossible. 

I  have  already  quoted  Dr.  Hodges  as  saying  that  he  had 
found  the  coronoid  process  broken  off  three  times  in  con- 
nection with  longitudinal  fractures  of  the  head  of  the 
radius. 

These,  if  I  except  my  own,  constitute  all  of  the  supposed 
examples  seen  in  the  living  subject,  of  which  I  find  any 
record ;  twelve  in  all. 

It  is  true,  however,  that  at  least  two  other  cases  have  been  reported 
to  me  by  letter,  of  which  the  writers  speak  with  great  confidence,  and 
the  authenticity  of  which  I  am  unable  to  dispute ;  but  in  neither  case 
is  the  testimony  to  me  satisfactory,  and  as  they  are  not  upon  record,  I 
shall  be  excused  from  discussing  their  merits. 

The  two  first  of  the  twelve  above  enumerated,  were  not  entirely  satis- 
factory to  Malgaigne  ;  the  third  is  spoken  of  cautiously  by  Sir  Astley 
Cooper,  as  if  it  needed,  in  addition  to  his  own  great  name,  the  indorse- 
ment of  the  "  London  council."  Dorsey  reports  his  case  upon  hearsay, 
and  the  result  is  quite  too  satisfactory  to  give  it  much  claim  to  credi- 
bility. Fahnestock's  case  is  to  our  mind  far  from  being  fully  proven. 
Couper's  case  is  doubted  by  Dr.  Johnson ;  and  the  New  Hampshire 
case  was  not  made  out  satisfactorily  to  either  the  jury  or  the  medical 
men.  Liston's  case  was  simply  impossible.  Duer's  case  could  have 
been  better  verified  at  a  later  period.  Having  never  seen  a  report 
of  the  three  cases  referred  to  by  Dr.  Hodges,  I  am  unable  to  form  any 
opinion  as  to  their  claims.  His  well-known  reputation,  however,  dis- 
poses me  to  accept  of  them  as  authentic. 

Certainly  it  is  not  upon  such  testimony  as  this  that  we  can  rely  to  sus- 
tain Mr.  Fergusson's  opinion  that  this  fracture  is  likely  to  occur  in  all 
dislocations  of  the  forearm  backward,  or  of  Malgaigne's  conjecture  that 
it  is  of  more  frequent  occurrence  than  the  published  cases  would 
seem  to  show.  Nor  will  it  be  regarded  as  conclusive,  that  the  beak 
of  the  process  is  often  found  broken  after  luxations  made  upon   the 


Ulna,  with 
epiphyses. 
(From  Gray.) 


806  FRACTUEES    OF    THE    ULNA. 

subject ;  since  between  luxations  thus  produced,  and  luxations  occur- 
ring in  the  living  subject  there  exists  this  important  difference :  that 
in  the  case  of  the  latter,  muscular  action  is  the  principal  agent  in  the 
production  of  the  dislocation,  while  in  the  former  it  is  the  external 
force  alone  which  drives  the  bone  from  its  socket. 

The  fact,  therefore,  that  so  few  cases  have  ever  been  reported,  and 
that  most  of  these  are  far  from  having  been  clearly  made  out,  remains 
presumptive  evidence  that  the  actual  cases  are  exceedingly  rare ;  but 
if  to  this  we  add  such  negative  evidence  as  is  furnished  by  actual  dis- 
sections, and  by  examinations  of  the  pathological  cabinets  of  the 
world,  we  think  the  testimony  is  almost  conclusive. 

Only  four  specimens  have  been  mentioned  by  any  of  the  surgical 
writers  known  to  me.  Sir  Astley  Cooper  says  that  a  person  was 
brought  to  the  dissecting-room  at  St.  Thomas's  Hospital,  who  had  been 
the  subject  of  this  accident.  "  The  coronoid  process,  which  had  been 
broken  off  within  the  joint,  had  united  by  a  ligament  only,  so  as  to 
move  readily  upon  the  ulna,  and  thus  alter  the  sigmoid  cavity  of  the 
ulna  so  much  as  to  allow  in  extension  that  bone  to  glide  backwards 
upon  the  condyles  of  the  humerus."^  Mr.  Bransby  Cooper  adds  in  a 
note  that  the  external  condyle  of  the  humerus  was  also  broken  and 
united  by  ligament. 

Samuel  Cooper  describes,  rather  obscurely,  a  specimen  contained  in 
the  University  College  Museum,  "  in  which  the  ulna  is  broken  at  the 
elbow,  the  posterior  fragment  being  displaced  backwards  by  the  action 
of  the  triceps;  the  coronoid  process  is  broken  off;  the  upper  head  of 
the  radius  is  also  dislocated  from  the  lesser  sigmoid  cavity  of  the 
ulna,  and  drawn  upwards  by  the  action  of  the  biceps.  In  this  com- 
plicated accident,  the  ulna  is  broken  in  two  places." 

Malgaigne  says  that  Velpeau  has  also  established  by  an  autopsy 
the  existence  of  a  fracture  of  the  coronoid  apophysis,  but  without 
having  given  any  further  particulars  in  relation  to  the  case. 

In  addition  to  these  examples,  Charles  Gibson,  of  Richmond,  Ya., 
has  stated  to  me,  by  letter,  that  he  has  in  his  possession  a  specimen  of 
this  fracture,  evidently  belonging  to  an  adult.  The  process  was  broken 
transversely  near  its  extremity,  and  has  united  again  quite  closely 
and  without  any  displacement,  and  without  ensheathing  callus. 

We  must  subject  these  specimens  to  analysis  also.  The  first  two 
were  complicated  with  other  fractures,  and  the  second,  especially, 
seems  to  have  been  a  general  crushing  of  all  the  bones  concerned  in 
the  formation  of  the  elbow-joint;  neither  of  them  could  have  been 
occasioned  by  contractions  of  the  brachialis  anticus,  while  only  that 
one  described  by  Sir  Astley  Cooper  could  have  been  the  result  of  a 
dislocation  of  the  forearm  backwards.  Of  the  specimen  said  to  have 
been  seen  by  Velpeau,  I  am  unable  to  speak  without  more  circum- 
stantial knowledge  of  its  condition.  Nor  can  I  speak  very  confidently 
of  that  belonging  to  my  distinguished  friend,  Dr.  Gibson,  of  Virginia. 
Notwithstanding  the  respect  which  I  entertain  for  his  opinion,  I  can- 
not avoid  a  suspicion  that  the  bone  was  never  broken  at  all,  since  J 

•  A.  Cooper,  Dislocations  and  Fractures,  p.  411. 


COEONOID    PROCESS    OF    THE    ULNA.  807 

find  it  more  easy  to  believe  that  he  is  deceived  by  certain  appearances, 
than  that  it  should  have  united  by  bone  again,  and  so  perfectly  as  not 
to  leave  any  line  of  separation  or  degree  of  displacement.  Certainly 
the  fracture  was  too  high  to  have  been  produced  by  the  action  of  the 
muscle,  if  such  a  thing  were  ever  possible ;  and  if  broken  by  a  dislo- 
cation, which  must  have  forced  it  violently  from  its  position,  as  the 
ulna  was  driven  upwards,  it  is  to  me  incredible  that  it  should  ever  be 
made  to  unite  again  so  perfectly. 

"We  are  therefore  left  as  before,  with  no  evidence  that  the  coronoid 
process  was  ever  broken  by  the  action  of  a  muscle,  and  with  only  one 
example  in  which  it  is  probable  that  a  fracture  occurred  as  a  conse- 
quence of  a  dislocation  of  the  radius  and  ulna  backwards.  If  then  it 
does  happen  that  in  this  dislocation  it  is  pretty  often  found  difficult 
or  impossible  to  retain  the  bones  in  place  without  aid,  it  will  be  the 
part  of  prudence  to  ascribe  this  troublesome  circumstance  to  some 
more  common  accident  than  a  fracture  of  the  coronoid  process;  per- 
haps to  a  fracture  of  some  portion  of  the  lower  end  of  the  humerus, 
or  to  a  disruption,  more  or  less  complete,  of  the  tendons  of  the  biceps 
and  brachialis  anticus,  together  with  the  ligaments  which  surround 
the  joint, 

(Just  as  this  volume  is  ready  for  the  press  my  attention  is  called 
by  Dr.  Castle,  of  this  city,  to  a  review  by  Zeis  of  a  paper  on  fractures 
of  this  apophysis,  published  by  Lotzbeck,  of  Munich,  in  1865.^  The 
original  paper  furnishes  five  cases,  to  which  the  reviewer  has  added 
four  more,  one  of  which,  Pennock's  case,  I  have  already  spoken  of. 
After  a  careful  reading  of  the  review,  I  fail  to  find  conclusive  evidence 
that  the  coronoid  process  was  broken  in  either  case.  The  evidence 
may  be,  indeed,  in  some  of  the  cases  probable,  but  never  conclusive, 
since  other  explanations  of  the  phenomena  presented  than  those  which 
are  here  offered,  would  prove  to  me  equally  satisfactory.) 

Causes. — It  is  probable  that  this  process  will  be  sometimes  broken 
in  a  fall  upon  the  palm  of  the  hand  ;  the  fofce  of  the  blow  being 
received  directly  upon  the  lower  end  of  the  radius,  and,  through  its 
numerous  muscles  and  ligamentous  attachments,  being  indirectly  con- 
veyed to  the  ulna,  producing  a  violent  concussion  of  the  coronoid 
process  against  the  trochlea  of  the  humerus,  and  resulting  finally  in 
a  fracture  of  this  process  and  a  dislocation  of  both  bones  of  the  fore- 
arm backwards.  The  gentleman  seen  by  Sir  Astley  had  fallen  upon 
his  extended  hand  while  in  the  act  of  running.  Brassard's  patient 
had  fallen  also  upon  his  hand  with  his  arm  extended  in  front.  Pen- 
nock's patient,  an  old  man  of  sixty  years,  had  fallen  upon  the  palm  of 
his  hand,  and  Fahnestock's  fell  upon  the  "  back  of  the  palm."  In  no 
other  case  is  the  point  upon  which  the  blow  was  received  particularly 
mentioned.  In  two  of  the  examples  mentioned  bj"-  Malgaigne  there 
was  a  luxation  of  the  forearm  backwards;  such  was  also  the  fact  in 
the  case  seen  by  Fahnestock ;  in  Couper's  case  it  was  dislocated  back- 
wards and  outwards,  and  in  Sir  Astley's  case  I  infer  that  there  was 
only  a  subluxation  of  the  ulna  backwards. 

'  Schmidt's  Jahrbuch  for  1866,  vol.  139,  p.  104  et  seq. 


808  FRACTUKES    OF    THE    ULNA. 

We  know  of  no  other  causes,  tberefore,  than  such  as  equally  tend 
to  produce  dislocations  at  the  elbow-joint,  unless  we  except  direct 
crushing  blows,  which  of  course  may  break  the  bones  at  any  point 
upon  which  the  force  happens  to  be  applied. 

Symptoms. — Partial  or  complete  displacement  of  the  ulna,  or  of  the 
radius  and  ulna  backwards,  accompanied  with  the  usual  signs  of  these 
luxations ;  to  which  may  be  possibly  added  crepitus ;  and  it  is  fair  to 
presume  that  in  'some  examples  the  fragment  carried  forwards  by  being 
driven  against  the  trochlea,  may  be  felt  displaced  and  movable  in  the 
bend  of  the  elbow.  Brassard  affirms  that  it  was  so  with  the  patient 
whom  he  saw.  If  only  the  summit  is  broken  off,  the  brachialis  anticus 
could  have  no  influence  upon  it;  but  if  it  were  broken  fairly  through 
the  base,  it  might  be  displaced  slightly  in  the  direction  of  the  action 
of  this  muscle. 

The  symptoms,  however,  which  have  been  regarded  as  most  diag- 
nostic, are  the  disposition  to  re-luxation  manifested  in  most  of  these 
examples  when  the  extension  has  been  discontinued;  and  especially 
the  fact  that  the  olecranon  was  particularly  prominent  when  the  arm 
was  extended,  but  that  it  resumed  its  natural  position  when  the  arm 
was  flexed  to  a  right  angle.  But  I  am  unable  to  understand  how 
either  of  these  circumstances  can  be  better  explained  upon  the  suppo- 
sition of  a  fracture  of  this  apophysis,  than  without  such  a  supposition. 
If  the  reduction  of  both  bones  is  once  effected,  even  though  the  sup- 
port of  the  coronoid  process  is  completely  lost,  the  head  of  the  radius, 
ought  to  prevent  a  re-luxation  unless  the  arm  is  disturbed  again;  nor 
can  I  understand  why,  when  the  elbow  is  bent,  the  re-luxation  is  less 
likely  to  occur;  since,  although  in  this  position  the  humerus  bears 
less  directly  upon  the  process,  the  difference  in  this  respect  must  be 
very  little,  for  in  whatever  position  the  arm  is  placed,  so  long  as  the 
radius  retains  its  position  the  ulna  cannot  be  drawn  very  forcibly 
against  the  humerus;  while,  on  the  other  hand,  by  flexing  the  arm 
the  power  of  the  bicejjS  and  of  such  fibres  of  the  brachialis  as  remain 
attached  to  the  ulna,  to  aid  in  the  maintenance  of  reduction,  is  com- 
pletely lost ;  and  at  the  same  moment  the  resistance,  and  consequent 
power  of  the  triceps  to  produce  the  luxation,  are  greatly  increased. 

In  short,  we  must  confess  that  we  are  here,  also,  notwithstanding 
the  confidence  with  which  writers  have  spoken  of  the  signs  of  this 
accident,  very  much  in  doubt;  nor  do  we  see  how  these  doubts  can 
be  removed  until  we  have  in  detail  the  symptoms  of  at  least  one 
example,  the  indubitable  existence  of  which  has  been  subsequently 
verified  by  dissection. 

Prognosis. — In  the  case  of  Cooper's  patient,  seen  several  months 
after  the  accident,  the  ulna  projected  backwards  while  the  arm  was 
extended,  but  it  was  without  much  difficulty  drawn  forwards  and  bent, 
and  then  the  deformity  disappeared.  He  thought  that  during  exten- 
sion the  ulna  slipped  back  behind  the  inner  condyle  of  the  humerus. 
Brassard's  patient,  seen  after  three  months,  retained  the  power  of  pro- 
nation and  supination,  with  also  extension,  but  flexion  was  completely 
impossible,  the  forearm  being  arrested  in  this  direction  by  the  small, 
slightly-movable  fragment  of  bone  in  front  of  the  elbow-joint,  and 


COEONOID    PROCESS    OF    THE    ULNA.  309 

which  was  supposed  to  be  the  process  itself.  Pennock's  old  man,  who 
had  met  with  the  accident  in  boyhood,  had  still  the  radius  luxated 
forwards  and  outwards,  and  the  olecranon  more  salient  backwards  than 
in  the  sound  arm.  Extension  and  flexion  were  nearly  but  not  quite 
complete.  Fahnestock  informs  us  that  his  patient  "  recovered  com- 
pletely," but  whether  without  deformity  or  maiming  we  are  not  told. 
Couper  says  the  bone  was  united  in  four  weeks,  and  that  only  a  slight 
deformity  and  a  little  stiffness  remained.  Physick's  patient  made  a 
perfect  recovery. 

Let  us  come  again  to  the  dissections.  Rejecting  the  doubtful 
specimen  belonging  to  Dr.  Gibson,  we  have  an  exact  account  of  only 
two,  and,  indeed.  Sir  Astley  Cooper  alone  has  described  the  mode  of 
union.  Samuel  Cooper  says  that  in  the  case  of  the  University  College 
specimen  the  radius  is  dislocated  forwards  and  upwards,  and  the  ole- 
cranon is  displaced  backwards,  but  he  does  not  say  whether  the 
coronoid  process  has  united,  nor  described  its  position  ;  but  Sir  Astley 
informs  us  that  in  the  example  seen  and  dissected  by  him  the  process 
was  united  by  ligament,  which  was  sufficiently  long  and  flexible  to 
allow  the  fragment  to  move  upwards  and  downwards  in  the  motions 
of  flexion  and  extension. 

In  the  absence  of  any  other  testimony,  we  may  be  allowed  to  ex- 
press an  opinion  that  when  the  fracture  has  taken  place  across  the 
summit  or  above  the  insertion  of  the  brachialis  anticus,  nothing  but  a 
ligamentous  union  can  be  regarded  as  possible,  since  the  fragment 
can  only  derive  nourishment  from  a  few  untorn  fibres  of  the  capsule 
and  perhaps  of  the  internal  lateral  ligaments ;  and  although  it  may 
not  be  displaced,  it  cannot  have  the  advantage  of  impaction,  upon 
which  alone,  I  suspect,  a  fracture  of  the  neck  of  the  femur  within  the 
capsule  must  rely  for  a  bony  union,  if  it  ever  does  so  unite.  If,  how- 
ever the  fracture  has  taken  place  at  the  base,  and  fortunately  it  has 
not  become  much  displaced  by  the  force  of  the  concussion  against  the 
humerus,  it  does  not  seem  to  me  so  impossible  that  under  favorable 
circumstances  a  bony  union  might  now  and  then  occur.  It  will  be 
remembered  that  a  good  portion  of  the  attachment  of  the  brachialis 
anticus  is  still  below  the  fracture,  and  the  remaining  fibres  are  not 
therefore  very  likely  to  displace  the  fragment,  especially  when  the  arm 
is  sufficiently  flexed,  so  as  to  properly  relax  this  muscle. 

It  will  be  of  small  importance,  however,  whether  the  union  is  bony 
or  ligamentous,  provided  only  there  is  not  great  displacement. 

Treatment. — Whatever  view  we  take  of  the  pathology  of  this  acci- 
dent, the  rational  mode  of  treatment  would  seem  to  consist  in  flexing 
the  arm  at  a  right  angle,  and  retaining  it  a  sufficient  length  of  time  in 
that  position  ;  not  forgetting,  however,  the  danger  of  anchylosis  from 
long-continued  confinement  in  one  position. 

An  angular  splint  may  be  useful  in  preventing  motion  at  first,  but 
I  think  it  ought  not  to  be  continued  beyond  seven  or  ten  days  at  the 
most.  After  this,  a  simple  sling  is  all  that  can  be  necessary,  since 
from  this  period  some  motion  must  be  given  to  the  joint  if  we  would 
take  the  proper  precautions  to  prevent  stiffness.  Sir  Astley  Cooper 
thought  the  limb  ought  to  be  kept  immovable  three  weeks,  and  Vel- 


310  FEACTUEES    OF    THE    ULNA. 

peau  preferred  four;  but  I  cannot  agree  with  them,  believing  that  the 
question  of  the  future  mobility  of  the  elbow-joint  is  vastly  more  im- 
portant than  the  question  of  a  bony  or  ligamentous  union  between 
the  fragments.  Couper  says  that  he  adopted  in  the  treatment  of  the 
case  reported  by  him,  extreme  flexion;  but  both  Physick  and  Fahne- 
stock  placed  the  arm  at  right  angles,  and  Sir  Astley  Cooper  has  re- 
commended the  same  position.  The  latter  position  has  always  the 
advantage  in  case  permanent  anchylosis  occurs,  and  the  former  cannot 
add  much  to  the  chance  of  complete  replacement  of  the  fragment. 

Bandages  are  only  serviceable  to  retain  the  splint  in  place,  and  they 
may  be  thrown  aside  as  soon  as  the  splint  is  removed. 

§  3.  Fractures  op  the  Olecranon  Process. 

Causes. — My  records  furnish  me  with  accounts  of  only  twelve  of  these 
fractures,  and,  so  far  as  I  have  been  able  to  ascertain,  all  were  occa- 
sioned by  falls  upon  the  elbow,  or  by  blows  inflicted  directly  upon 
the  part.  Malgaigne  has,  however,  been  able  to  collect  accounts  of 
six  examples  of  fracture  of  the  olecranon,  produced,  as  is  affirmed,  by 
the  violent  action  of  the  triceps;  as  in  pushing  with  the  arm  slightly 
flexed,  in  throwing  a  ball,  in  plunging  into  the  water  with  the  arms 
extended,  etc. ;  but  only  four  of  these  reported  examples  does  he  think 
are  sufficiently  authenticated  to  entitle  them  to  be  received  as  facts  ; 
nor  do  I  think  it  possible  to  affirm  positively  that  in  any  instance, 
where  the  whole  process  is  broken  off,  the  triceps  alone  has  occasioned 
the  separation.  For  example,  Capiomont  reports  the  case  of  a  cavalier, 
who,  being  intoxicated,  was  thrown  head  foremost  from  his  horse,  and, 
striking  probably  upon  his  head,  was  found  to  have  broken  the 
olecranon  process.  We  do  not,  in  this  example,  see  evidence  alone 
of  a  forcible  contraction  of  the  triceps,  but  also  of  violent  pressure 
against  the  hand  and  in  the  direction  of  the  axis  of  the  forearm  toward 
the  elbow-joint,  by  which  the  olecranon  process  might  have  been  so 
thrown  forwards  against  the  fossa  of  the  humerus  as  to  cause  its 
separation.  The  same  explanation  might  apply  to  several  of  the 
other  examples. 

Point  and  Direction  of  Fracture ;  Displacement,  etc. — The  process  may 
be  broken  at  its  summit,  at  its  base,  or  intermediate  between  these  two 
extremes,  the  last  of  which  is  the  most  common. 

It  is  probable  that  when  the  action  of  the  triceps  alone  has  produced 
the  fracture,  it  will  be  found  that  only  that  portion  which  receives  the 
insertion  of  the  triceps  has  been  broken  oft".  Malgaigne,  who  has 
been  able  to  find  upon  record  only  two  cases  of  a  fracture  of  the  ex- 
treme end  of  the  process,  declares  that  they  were  both  occasioned  by 
muscular  action. 

Fractures  of  the  middle  are  generally  transverse,  or  only  slightly 
oblique,  occurring  in  the  line  of  the  junction  of  the  epiphysis  with 
the  diaphysis. 

Fractures  through  the  base  are  generally  quite  oblique,  the  line 
of  fracture  extending  from  before  downwards  and  backwards,  so  that 


FEACTUEES    OF    THE    OLECRANON    PROCESS, 


311 


Fiff.  101. 


Fractures  at  the  base. 


not  only  the  whole  of  the  process, 
but  a  portion  of  the  back  of  the 
shaft  is  carried  away  ;  and  this  ac- 
cident can  scarcely  happen,  except 
by  a  blow  received  upon  the  lower 
end  of  the  humerus,  directly  in 
front  of  the  process ;  or,  what  would 
amount  to  the  same  thing,  by  a 
blow  from  behind,  received  upon 
the  ulna  just  below  the  olecranon 
process,  or  by  wrenching  the  fore- 
arm violently  back,  while  the  hume- 
rus is  fixed. 

The  only  displacement  to  which  the  upper  fragment  seems  to  be 
liable,  is  in  the  direction  of  the  triceps ;  and  the  degree  of  this  dis- 
placement does  not  depend  so  much  upon  the  point  at  which  the 
fracture  has  taken  place  as  upon  the  violence  which  has  occasioned  it, 
the  extent  of  the  disruption  of  the  ligaments,  aponeurosis  of  the  triceps 
and  of  the  capsule,  and  upon  whether,  since  the  accident,  the  arm  has 
been  flexed  or  kept  extended. 

In  three  instances,  I  have  found  distinct  crepitus  immediately  after 
the  fracture  had  occurred,  produced  by  only  moving  the  fragment 
laterally,  showing  plainly  that  little  or  no  displacement  had  taken 
place.  The  following  example  will  show  also  that  this  displacement 
does  not  always  happen  even  after  the  lapse  of  several  days,  and  where 
no  surgical  treatment  has  been  adopted. 

Samuel  Duckett,  a3t,  14,  fell  upon  the  point  of  the  elbow,  and  two 
days  after  was  admitted  to  the  Buffalo  Hospital  of  the  Sisters  of 
Charity,  The  elbow  was  then  much  swollen,  but  no  crepitus  could 
be  detected,  and  he  could  nearly  straighten  his  arm  by  the  action  of 
the  triceps.  On  the  sixth  day,  the  swelling  having  sufficiently  sub- 
sided, a  distinct  crepitus  was  discovered  when  the  olecranon  process 
was  seized  between  the  fingers,  and  moved  laterally.  We  extended 
the  arm  immediately,  and  applied  a  long  gutta-percha  splint  to  the 
whole  front  of  the  arm  and  forearm,  securing  it  in  place  with  a  roller. 
On  the  eleventh  day,  five  days  after  the  first  dressing,  the  splint  was 
taken  offj  and  its  angle  at  the  elbow-joint  slightly  changed ;  and  this 
was  repeated  every  day  until  the  twenty-second  from  the  time  of  the 
accident.  The  splint  was  then  finally  removed,  when  the  fragment 
was  found  to  be  united  without  any  perceptible  displacement,  and  the 
motions  of  the  joint  were  unimpaired. 

It  must  not  be  inferred,  however,  that  it  is  always  prudent  to  leave 
this  fracture  thus  unsupported,  since  it  has  occasionally  happened 
that  the  displacement,  which  did  not  exist  at  first,  has  taken  place  to 
the  extent  of  half  an  inch  or  more,  after  the  lapse  of  several  days. 
Mr.  Earle  mentions  a  case  in  which  the  separation  did  not  take  place 
until  the  sixth  day,  when  it  was  occasioned  by  the  patient's  attempting 
to  tie  his  neckcloth, 

Sy7npioms. — The  usual  signs  of  a  fracture  of  the  olecranon  process 
are,  when  the  fragments  are  not  separated,  crepitus  discovered  espe- 


312  FRACTUEES    OF    THE    ULNA. 

ciallj  bj  seizing  the  process,  and  moving  it  laterally ;  or,  when  dis- 
placement has  actually  taken  place,  the  crepitus  may  be  discovered 
sometimes  by  extending  the  forearm,  and  pressing  the  upper  fragment 
downwards  until  it  is  made  to  touch  the  lower  fragment ;  the  existence 
of  a  palpable  depression  between  the  fragments,  partial  jflexion  of  the 
forearm;  and  total  inability,  on  the  part  of  the  patient,  to  straighten 
it  completely,  or  even  to  flex  the  arm  in  some  cases.  If  the  fragments 
do  not  separate,  gentle  flexion  and  extension  of  the  arm,  while  the 
finger  rests  upon  the  process,  may  enable  us  to  detect  the  fracture. 

It  will  sometimes  happen  that,  owing  to  the  rapid  occurrence  of 
tumefaction,  the  evidences  of  a  fracture  will  be  quite  equivocal ;  but, 
in  all  cases  where  a  severe  injury  has  been  inflicted  upon  the  point 
of  the  elbow,  it  will  be  well  to  suspend  judgment  until,  by  repeated 
examinations,  made  on  successive  days,  the  question  is  determined. 
Meanwhile,  the  arm  ought  to  be  kept  constantly  in  an  extended  posi- 
tion, as  if  a  fracture  was  known  to  exist. 

Prog7iosis. — In  a  large  majority  of  cases,  this  process  becomes  re- 
united to  the  shaft  by  ligament,  which  may  vary  in  length  from  a 
line  to  an  inch  or  more,  and  which  is  more  or  less  perfect  in  different 
cases.  Sometimes  it  is  composed  of  two  separate  bands,  with  an 
intermediate  space,  or  the  ligament  may  have  several  holes  in  it ;  at 
other  times  it  is  composed  in  part  of  bone  and  in  part  of  fibrous  tissue  ; 
but  most  frequently  it  is  a  single,  firm,  fibrous  cord,  whose  breadth  and 
thickness  are  less  than  that  of  the  process  to  which  it  is  attached. 

If  the  fragments  are  maintained  in  perfect  apposition,  a  bony  union 
may  occur,  yet  it  is  not  invariably  found  to  have  taken  place,  even 
under  these  circumstances.  Malgaigne  thinks,  also,  he 'has  seen  one 
case  in  which  there  was  neither  bone  nor  fibrous  tissue  deposited  be- 
tween the  fragments.  This  was  an  ancient  fracture  at  the  base  of  the 
olecranon;  the  superior  fragment  remained  immovable  during  the 
flexion  and  extension  of  the  arm,  yet  it  could  be  moved  easily  from 
side  to  side. 

In  my  own  cases,  I  have  five  times  found  the  fragments  united 
without  any  appreciable  separation,  and  have  presumed  that  the  union 
was  bony.  One  of  these  examples  I  have  already  mentioned ;  the 
second,  was  in  the  person  of  a  lady  aged  about  forty  years,  who, 
having  fallen  down  a  flight  of  steps  on  the  8th  of  September,  1857, 
sent  for  me  immediately.  I  found  a  large  bloody  tumor  covering  the 
elbow  joint,  but  there  was  no  difficulty  in  detecting  a  fracture  of  the 
olecranon  process.  It  was  easily  moved  from  side  to  side,  and  this 
motion  was  accompanied  with  a  distinct  crepitus.  During  the  first 
week,  the  arm  was  only  laid  upon  a  pillow,  but  as  it  was  found  to 
become  gradually  more  flexed,  and  the  swelling  having  in  a  great 
measure  subsided,  the  arm  was  nearly,  but  not  quite,  straightened, 
and  a  long  gutta-percha  splint  applied  to  the  palmar  surface  of  the 
forearm  and  arm.  The  fragments  united  in  about  twenty  or  twenty- 
five  days,  and  without  separation,  so  far  as  could  be  discovered  in  a 
very  careful  examination. 

The  third  example  to  A^hich  I  have  referred,  occurred  in  a  boy 
fourteen  years  old,  and  was  treated  by  Dr.  Benjamin  Smith,  of  Berk- 


FRACTUEES  OF  THE  OLECRANON  PROCESS, 


313 


F\r,.  102. 


shire,  Massachusetts.  Sixty-nine  years  after,  he  being  then  eighty- 
three  years  old,  I  found  the  olecranon  process  united  apparently  by 
bone,  but  to  that  day  he  had  been  unable  to  straighten 
the  arm  completely,  or  to  supine  it  freely. 

In  one  instance  I  found  the  fragment,  after  the  lapse 
of  one  year,  united  by  a  ligament,  which  seemed  to  be 
about  one-quarter  of  an  inch  in  length,  and  the  arm 
appeared  to  be  in  all  respects  as  perfect  as  the  other, 
lie  could  flex  and  extend  it  freely. 

In  the  two  following  examples,  also,  the  bond  of  union 
was  ligamentous : — 

John  Carbony,  ast.  18,  having  broken  the  olecranon, 
it  was  treated  with  a  straight  splint.  Nine  years  after, 
I  found  the  process  united  by  a  ligament  half  an  inch  in 
length,  and  he  could  nearly,  but  not  entirely,  straighten 
the  arm.  In  all  other  respects  the  functions  and  motions 
of  the  arm  were  perfect. 

A  lad,  set.  15,  was  brought  to  me  by  Dr.  Lauderdale, 
a  very  excellent  surgeon  in  the  town  of  Geneseo,  Liv- 
ingston Co.,  N.  Y.,  whose  olecranon  process  had  been 
broken  by  a  fall  six  months  before,  and  at  the  same 
time  the  head  of  the  radius  had  been  dislocated  for- 
wards. I  found  the  radius  in  place,  and  the  olecranon  process  united 
by  a  ligament  about  half  an  inch  in  length.  He  was  not  able  to 
straighten  the  arm  completely,  the  forearm  remaining  at  an  angle  of 
45°  with  the  arm. 

Treatment. — It  will  surprise  the  student  who  is  yet  unacquainted 
with  the  literature  of  our  science,  to  learn  that  in  relation  to  the  treat- 
ment of  a  fracture  of  the  olecranon  process,  a  wide  difference  of  opinion 
has  been  entertained  as  to  what  ought  to  be  the  position  of  the  arm 
and  the  forearm,  in  order  to  the  accomplishment  of  the  most  favorable 
results ;  and  that,  while  some  insist  upon  the  straight  position  as  essen- 
tial to  success,  others  prefer  a  sliglitly  flexed  position,  and  still  others 
have  advocated  the  right-angled  position.  Thus,  Hippocrates,  and 
nearly  all  of  the  earlier  surgeons,  down  to  a  period  so  late  as  the  latter 
part  of  the  last  century,  directed  that  the  arm  should  be  placed  in  a 
position  of  semi-flexion ;  Boyer,  Desault,  and,  after  them,  most  of  the 
French  surgeons  of  our  own  day,  prefer  a  position  in  which  the  fore- 
arm is  very  slightly  bent  upon  the  arm ;  while  Sir  Astley  Cooper,  and 
a  large  majorit}'-  of  the  English  and  American  surgeons,  employ  com- 
plete or  extreme  extension. 

The  arguments  presented  by  the  advocates  and  antagonists  of  these 
various  plans  deserve  a  moment's  consideration. 

In  favor  of  the  position  of  semi-flexion,  requiring  no  splints,  and, 
in  the  opinion  of  some  writers,  not  even  a  bandage,  but  only  a  sling 
to  support  the  forearm,  it  is  claimed  that  it  leaves  the  patient  at  liberty 
at  once  to  walk  about  and  to  move  the  elbow-joint  freely,  so  soon  at 
least  as  the  subsidence  of  the  swelling  and  pain  will  permit,  and  that 
in  this  way  the  danger  of  anchylosis  is  greatly  diminished  ;  that,  more- 
over, if  anchylosis  should  unfortunately  occur,  the  limb  is  in  a  much 
21 


314  FRACTURES    OF    THE    ULNA. 

better  position  for  the  proper  performance  of  its  most  ordinary  func- 
tions than  if  it  were  extended.  Some  have  also  added  to  this  argu- 
ment a  statement  that  a  fibrous  union,  under  any  circumstances,  is 
inevitable,  and  that  it  is  a  matter  of  little  consequence  whether  the 
ligament  thus  formed  is  long  or  short,  since  in  either  condition  it  will 
be  equally  serviceable. 

In  reply  to  these  statements,  it  may  be  said  briefly  that  they  are 
nearly  all  based  upon  false  premises,  or  that  they  have  been  proven 
in  themselves  to  be  essentially  erroneous. 

Anchylosis  is  always  a  serious  event,  which  by  all  possible  means 
the  surgeon  will  seek  to  prevent,  but  position  has  nothing  to  do  with 
determining  this  result ;  when  it  does  occur,  it  may  usually  be  ascribed 
either  to  the  severity  and  complications  of  the  original  injury,  to  the 
violence  of  the  consequent  inflammation,  or  to  having  neglected,  at  a 
proper  period  and  with  sufficient  perseverance,  to  move  the  joint. 

That  a  fibrous  union  is  inevitable  under  any  circumstances,  has 
been  fully  proven  to  be  an  error  ;  and  it  has  been  equally  proven  that 
the  functions  of  the  arm  are  generally  impaired  in  proportion  to  the 
length  of  the  uniting  medium. 

The  only  argument  which  remains,  and  which  really  possesses  any 
weight,  is,  that,  if  permanent  anchylosis  does  actually  occur,  the  arm, 
when  semi-flexed,  is  in  a  better  position  for  the  performance  of  its 
ordinary  functions ;  and  this,  considered  as  an  argument  in  favor  of 
the  universal  or  even  general  adoption  of  the  flexed  position,  is  suc- 
cessfully met  by  a  statement  of  the  infrequency  of  permanent  anchy- 
losis after  a  simple  fracture,  when  the  case  has  been  properly  treated, 
whether  by  the  flexed  or  straight  position  ;  while,  if  the  limb  is  flexed, 
a  maiming,  as  a  result  of  the  great  length  of  the  intermediate  liga- 
ment, is  almost  inevitable. 

Yet  if,  in  any  case,  from  the  great  severity  and  complications  of  the 
injury,  especially  in  certain  examples  of  compound  and  comminuted 
fracture,  it  were  to  be  reasonably  anticipated  that  permanent  bony 
anchylosis  must  result,  or  even  where  the  probabilities  were  strongly 
that  way,  the  surgeon  might  be  justified  in  selecting  for  the  limb,  at 
once,  the  position  of  semi-flexion  ;  or  he  might  leave  the  arm  without 
a  splint,  and  at  liberty  to  draw  up  spontaneously  and  gradually  to  this 
position,  as  it  is  always  very  prone  to  do. 

In  favor  of  moderate,  but  not  complete  extension,  it  is  claimed  that 
it  is  less  fatiguing  than  the  latter  position,  while  it  accomplishes  a 
more  exact  apposition  of  the  fragments,  if  they  happen  to  be  brought 
actually  into  contact. 

I  am  unable,  however,  to  understand  how  the  apposition  can  be 
rendered  less  exact  by  complete  extension,  unless  by  this  is  meant  a 
degree  of  extension  beyond  that  which  is  natural,  and  which,  I  am 
well  aware,  is  permitted  to  the  elbow-joint  when  this  posterior  brace 
is  broken  off.  It  would  certainly  derange  the  fragments  to  place  the 
arm  in  this  extreme  condition  of  extension — that  is,  in  a  condition  of 
extension  approaching  dorsal  flexion,  which  is  beyond  what  is  natural. 
Indeed,  perhaps  we  may  admit  that,  in  order  to  perfect  apposition, 
the  extension  ought  to  be  less  by  one  or  two  degrees  than  what  is 


FRACTURES  OF  THE  OLECRANON  PROCESS.     315 

natural,  sufficient  to  compensate  for  the  trifling  amount  of  effusion 
which  may  be  presumed  to  have  occurred  in  the  olecranon  fossa,  and 
which  would  prevent  the  process  from  sinking  again  fairly  into  its 
fossa. 

As  to  its  being  less  fatiguing,  it  is  well  known  to  those  accustomed 
to  treat  fractures  of  the  thigh  by  permanent  extension  that  the  muscles 
rapidly  acquire  a  tolerance,  which  soon  dissipates  all  feeling  of  fatigue, 
and  that,  after  a  few  hours,  or  days  at  most,  the  patients  express  them- 
selves as  being  more  comfortable  in  this  position  than  in  the  flexed. 

Finally,  the  advocates  of  complete,  natural  extension  claim  that  in 
this  position  alone  is  the  triceps  most  perfectly  relaxed,  and  conse- 
quently the  most  important  indication,  namely,  the  descent  of  the  ole- 
cranon, most  fully  accomplished.  In  this  opinion  we  also  concur;  and 
regarding  all  other  considerations,  in  the  early  days  of  the  treatment, 
as  secondary  to  this  one,  we  unhesitatingly  declare  our  preference  for 
what  has  been  called  the  "position  of  complete  extension,"  as  opposed 
to  flexion,  semi-flexion,  or  extreme  extension. 

It  only  remains  for  us  to  determine  by  what  means  the  limb  can  be 
best  maintained  in  the  extended  position,  and  the  olecranon  process 
most  easily  and  effectually  secured  in  place. 

For  this  purpose  a  variety  of  ingenious  plans  have  been  devised : 

Fi<r.  103. 


Sir  Astley  Cooper's  method. 

such  as  the  compress  and  "  figure-of-8"  bandage  of  Duverney,  without 
splints;  or  a  similar  bandage  employed  by  Desault,  with  the  addition 
of  a  long  splint  in  front ;  the  circular  and  transverse  bandages  of  Sir 
Astley  Cooper,  with  lateral  tapes  to  draw  them  together,  to  which 
also  a  splint  was  added ;  and  many  other  modes  not  varying  essentially 
from  those  already  described,  but  nearly  all  of  which  are  liable  to  one 
serious  objection,  namely,  that  if  they  are  applied  with  sufficient  firm- 
ness to  hold  upon  the  fragment,  and  Boyer  says  they  "  ought  to  be 
drawn  very  tight,"  they  ligate  the  limb  so  completely  as  to  interrupt 
its  circulation,  and  expose  the  limb  greatly  to  the  hazards  of  swelling, 
ulceration,  and  even  gangrene.  How  else  is  it  possible  to  make  the 
bandage  effective  upon  a  small  fragment  of  bone,  scarcely  larger  than 
the  tendon  which  envelops  its  upper  end,  and  with  no  salient  points 
against  which  the  compress  or  the  roller  can  make  advantageous 
pressure?  If,  then,  these  accidents — swelling,  ulceration,  and  gan- 
grene— are  not  of  frequent  occurrence,  it  is  only  because  the  bandage 
has  not  been  generally  applied  "  very  tight,"  and  while  it  has  done 
no  harm,  it  has  as  plainly  done  no  good. 

The  dangers  to  which  I  allude  may  be  easily  avoided,  without  re- 
laxing the  security  afforded  by  the  compress  and  bandage,  by  a 


316 


FRACTURES    OF    THE    ULNA. 


method  which  is  very  simple,  and  the  value  of  which  I  have  already 
sufficiently  determined  by  my  own  practice. 

The  surgeon  will  prepare,  extemporaneously  always,  for  no  single 
pattern  will  fit  two  arms,  a  splint,  from  a  long  and  sound  wooden 
shingle,  or  from  any  piece  of  thin,  light  board.  This  must  be  long 
enough  to  reach  from  near  the  wrist-joint  to  within  three  or  four 
inches  of  the  shoulder,  and  of  a  width  equal  to  the  widest  part  of  the 
limb.  Its  width  must  be  uniform  throughout,  except  that,  at  a  point 
corresponding  to  a  point  three  inches,  or  thereabouts,  below  the  top 
of  the  olecranon  process,  there  shall  be  a  notch  on  each  side,  or  a 
slight  narrowing  of  the  splint.     One  surface  of  the  splint  is  now  to  be 

Fiff.  104. 


The  author's  method. 


thickly  padded  with  hair  or  cotton-batting,  so  as  to  fit  all  of  the  in- 
equalities of  the  arm,  forearm,  and  elbow,  and  the  whole  covered 
neatly  with  a  piece  of  cotton  cloth,  stitched  together  upon  the  back 
of  the  splint.  Thus  prepared,  it  is  to  be  laid  upon  the  palmar  surface 
of  the  limb,  and  a  roller  is  to  be  applied,  commencing  at  the  hand 
and  covering  the  splint,  by  successive  circular  turns,  until  the  notch 
is  reached,  from  which  point  the  roller  is  to  pass  upwards  and  back- 
wards behind  the  olecranon  process  and  down  again  to  the  same 
point  on  the  opposite  side  of  the  splint ;  after  making  a  second  oblique 
turn  above  the  olecranon,  to  render  it  more  secure,  the  roller  may 
begin  gradually  to  descend,  each  turn  being  less  oblique,  and  passing 
through  the  same  notch,  until  the  whole  of  the  back  of  the  elbow- 
joint  is  covered.  This  completes  the  adjustment  of  the  fragments, 
and  it  only  remains  to  carry  the  roller  again  upwards,  by  circular 
turns,  until  the  whole  arm  is  covered  as  high  as  the  top  of  the  splint. 

The  advantage  of  this  mode  of  dressing  must  be  apparent.  It 
leaves,  on  each  side  of  the  splint,  a  space  upon  which  neither  the 
splint  nor  bandage  can  make  pressure,  and  the  circulation  of  the  limb 
is,  therefore,  unembarrassed,,  while  it  is  equally  efi'ective  in  retaining 
the  olecranon  in  place,  and  much  less  liable  to  become  disarranged. 

Before  the  bandage  is  applied  about  the  elbow-joint,  the  olecranon 
must  be  drawn  down,  as  well  as  it  can  be,  by  pressure  with  the 
fingers,  and  a  compress  of  folded  linen,  wetted  to  prevent  its  sliding, 
must  be  placed  partly  above  and  partly  upon  the  process ;  at  the  same 
time,  also,  care  must  be  taken  that  the  skin  is  not  folded  in  between 
the  fragments. 

This  dressing  ought,  no  doubt,  to  be  applied  immediately,  since,  if 
we  wait,  as  Boyer  seems  to  advise,  until  the  swelling  has  subsided,  it 


FRACTURES  OF  THE  OLECRANON"  PROCESS.     317 

will  be  found  much  more  difficult  to  straighten  the  arm  completely 
than  it  would  have  been  at  first,  and  the  olecranon  process  will  be  more 
drawn  up  and  fixed  in  its  abnormal  position.  Something  will  be 
gained  by  these  means,  adopted  early,  even  if  the  bandage  cannot  be 
applied  tightly,  and  moderate  bandaging  will  not  in  any  way  interfere 
with  the  proper  and  successful  treatment  of  the  inflammation.  We 
must  always  keep  in  mind,  however,  the  fact  that  the  fracture  being 
usually  the  result  of  a  direct  blow,  considerable  inflammation  and 
swelling  around  the  joint  are  about  to  folloAV  rapidly  ;  and  on  each  suc- 
cessive day,  or  oftener  if  necessary,  the  bandages  must  be  examined 
carefully,  and  promptly  loosened  whenever  it  seems  to  be  necessary. 
For  this  purpose  it  is  better  not  to  unroll  the  bandages,  but  to  cut 
them  with  a  pair  of  scissors,  along  the  face  of  the  splint,  cutting  only 
a  small  portion  at  a  time,  and  as  they  draw  back,  stitch  them  together 
again  ligbtly ;  and  thus  proceed  until  the  whole  has  been  rendered 
sufficiently  loose. 

As  soon  as  the  inflammation  has  subsided,  and  as  early  sometimes 
as  the  fifth  or  seventh  day,  the  dressings  ought  to  be  removed  com- 
pletely ;  and  while  the  fingers  of  the  surgeon,  resting  upon  the  compress, 
sustain  the  process,  the  elbow  ought  to  be  gently  and  slightly  flexed 
and  extended  two  or  three  times.  From  this  time  forward,  until  the 
union  is  consummated,  this  practice  should  be  continued  daily,  only 
increasing  the  flexion  each  time,  as  the  inflammation  and  pain  may 
permit.  If  it  is  thought  best,  at  length,  to  change  the  angle  of  the 
arm,  and  to  flex  it  more  and  more,  it  may  be  done  easily  by  substi- 
tuting a  very  thick  sheet  of  gutta  percha  for  the  board. 

Diefifenbach  has  several  times,  in  old  fractures  of  both  the  olecranon 
and  patella,  where  the  fragments  were  dragged  far  apart,  divided  the 
tendons,  so  as  to  be  able  to  bring  the  two  portions  together,  and,  by 
friction  of  them  "one  upon  the  other,  has  endeavored  to  excite  such 
action  as  might  end  in  the  formation  of  a  shorter  and  a  firmer  bond  of 
union.  In  some  instances,  it  is  said,  considerable  benefit  was  obtained, 
after  all  other  means  had  failed;  in  others,  the  result  was  negative. 
One  example  of  an  old  ununited  fracture  of  the  olecranon  is  mentioned, 
in  which  he  divided  the  tendon  of  the  triceps,  secured  the  upper  frag- 
ment in  place,  and  every  fourteen  days  rubbed  it  well  against  the 
lower  one;  in  three  months  "  the  union  was  firm."^ 

The  practice,  not  without  its  hazards,  needs  further  observations  to 
determine  its  value. 

Eecently  a  gentleman  called  upon  me  with  his  son,  aged  seven  years, 
who  had  an  unreduced  dislocation  of  the  radius  and  ulna  backwards 
of  nine  weeks'  standing.  While  reducing  this  dislocation,  it  being 
necessary  to  flex  the  arm  forcibly,  the  epiphysis  constituting  the 
olecranon  process  gave  way,  and  became  separated  from  one-half  to 
three-quarters  of  an  inch.  This  is  the  only  example  of  separation  of 
this  epiphysis  which  has  come  to  my  knowledge.  I  have,  however, 
twice  since  broken  the  olecranon  in  attempts  to  reduce  old  dislocations 

'  Dieffenbach,  American  Journal  of  Medical  Science,  vol.  xxix.  p.  478 ;  from 
Casper's  Wochenschrift,  Oct.  2,  1841. 


818 


FRACTUEES  OF  THE  EADIUS  AND  ULNA. 


of  the  radius  and  ulna  backwards,  and  I  have  not  regretted  the  occur- 
rence, since  it  enabled  me  to  reduce  the  dislocations  without  cutting 
the  triceps. 


CHAPTEH   XXIII. 


FRACTURES  OF  THE  RADIUS  AND  ULNA. 

Causes. — In  a  large  majority  of  the  examples  of  this  fracture  seen 
by  me,  which  have  been  of  such  a  character  as  to  warrant  an  attempt 
to  save  the  limb,  the  accident  has  been  occasioned  by  a  fall  upon  the 
palm  of  the  hand  while  the  arm  was  extended  in  front  of  the  body. 
Yet  this  cause  is  not  so  constant  as  in  fractures  of  the  radius  alone, 
since  a  considerable  number  have  been  occasioned  by  direct  blows  ; 
and  if  we  were  to  add  to  this  estimate  all  of  those  bad  compound  frac- 
tures which  have  demanded  immediate  amputation,  the  proportion  of 
fractures  occasioned  by  direct  and  indirect  blows  might  be  found  to 
be  pretty  nearly  balanced. 

Point  of  Fracture,  Qharacter,  Direction  of  Displacement,  &c. — In  a 
record  of  sixty  fractures  of  both  bones,  not  including  gunshot  frac- 
tures, or  those  demanding  immediate  amputation,  I  have  found  six 
broken  in  the  upper  third,  twenty-four  in  the  middle  third,  and  thirty 
in  the  lower  third. 

Fig.  105. 


Fracture  in  the  middle  third. 

In  one  case  the  radius  was  broken  three-quarters  of  an  inch  above 
its  lower  end,  and  the  ulna  about  one  inch  below  the  coronoid  process. 
Four  of  the  fractures  belonging  to  the  lower  third  were  probably 
epiphyseal  separations. 

Forty-six  were  simple,  eight  compound,  one  was  comminuted,  three 
both  compound  and  comminuted,  one  complicated  with  a  fracture  of 
the  humerus,  and  one  with  a  partial  luxation  of,  the  lower  end  of  the 
radius.  With  three  exceptions,  all  of  these  more  serious  accidents 
were  arranged  among  fractures  of  the  lower  third,  and  generally  the 
bones  had  been  broken  near  the  wrist. 

Partial  fractures  have  been  frequently  observed,  but  having  treated 
of  these  accidents  fully  in  the  general  chapter  on  Incomplete  Frac- 
tures, I  shall  not  think  it  necessary  to  make  any  further  allusion  to 
them  in  this  place. 

Prognosis. — Generally  these  bones  unite  in  from  twenty  to  thirty 
days;  but  I  have  seen  the  union  occasionally  delayed  considerably 


FRACTURES  OF  THE  RADIUS  AND  ULNA. 


319 


Fracture  in  the 
lower  third. 


beyond  this  time,  and  this  delay  has  occurred  especially        Fig. 
in  the  case  of  the  radius.     Thus,  in  three  cases  of  com-  -^ 

pound  and  comminuted  fracture,  the  ulna  united  within 
four  or  five  weeks,  while  the  radius  did  not  unite  until 
the  ninth  or  tenth  week.  Twice  in  simple  fractures  the 
ulna  has  united  in  the  usual  time,  but  the  radius  not 
until  the  sixteenth  week.  Once  the  ulna  has  united 
promptly  and  the  radius  remained  ununited  at  the  end 
of  two  years,  at  which  time  I  practised  resection  of  the 
broken  ends  of  the  radius,  and  union  was  speedily  es- 
tablished. 

On  the  other  hand,  I  have  once  seen  the  union  de- 
layed four  months  in  the  case  of  the  ulna,  when  the 
radius  had  united  in  the  usual  time;  and  in  one  ex- 
ample of  compound  fracture  both  bones  refused  to 
unite  until  after  the  fifth  month. 

Thirty-three  of  the  whole  number  have  united  with- 
out any  appreciable  deformity,  and  fifteen  are  known 
to  have  left  some  marked  defect,  while  two  have  re- 
sulted finally  in  the  loss  of  the  arm.  Of  the  remainder 
I  cannot  speak  positively. 

I  have  seen  the  fragments  deviate  slightly  in  almost 
every  direction,  but  most  often  it  has  been  noticed  that 
the  deviation  was  to  the  radial  or  ulnar  sides.  Thus,  in  three  examples, 
two  of  which  had  been  compound  fractures,  the  bones  have  united 
in  such  a  position  as  that  from  the  point  of  fracture  downwards  the 
forearm  has  been  deflected  to  the   ulnar  side,  and  a 
marked  projection  has  been  left  at  the  seat  of  fracture 
on  the  radial  side;  while  in  two  examples,  both  of 
which  were  simp'le  fractures,  exactly  the  opposite  con- 
dition has  obtained,  the  lower  part  of  the  forearm 
being  deflected  to  the  radial  side. 

In  a  majority  of  cases  the  hand  has  been  left  with 
some  tendency  to  pronation;  in  many  instances  this 
tendency  was  very  slight  and  scarcely  appreciable, 
but  in  others  it  has  been  quite  marked,  so  that  the 
patients  have  been  wholly  unable  to  supine  the  fore- 
arm except  by  a  motion  of  the  humerus  in  its  socket. 

From  what  has  been  said  it  must  be  seen  that  the 
prognosis  in  these  accidents  takes  the  widest  range : 
for  while  a  larger  proportion  than  in  the  case  of  almost 
any  other  of  the  long  bones,  unite  without  any  appre- 
ciable deformity,  a  considerable  number  delay  to 
unite  or  do  not  unite  at  all,  and  some,  even  where  the 
fracture  is  most  simple,  result  in  the  complete  loss  of 
the  limb.  I  am  not  now  speaking  of  those  more  severe 
accidents  in  which  the  limb  is  at  once  condemned  to 
amputation,  and  which,  in  the  case  of  the  arm,  are 
numerous;  but,  as  I  have  already  mentioned,  our 
observations  here  apply  only  to  cases  which  came 
under  treatment  with  a  view  especially  to  the  fracture. 


Fiir.  107. 


Union   with   slight 
lateral  displacement. 


820  FRACTURES    OF    THE    RADIUS    AND    ULNA. 

I  shall  state  the  facts  more  fully,  and  then  perhaps  we  shall  think 
it  proper  to  inquire  why,  when,  as  a  rule,  the  treatment  is  found  to  be 
so  simple  and  successful,  occasionally,  and  pretty  often  indeed,  it  re- 
sults so  disastrously. 

A  boy,  aged  about  ten  years,  fell  from  a  tree,  April  22,  1856,  frac- 
turing the  right  forearm  near  the  lower  end  of  the  middle  third.  It 
was  evident  that  he  had  fallen  upon  the  palm  of  his  hand,  as  the  lower 
fragments  were  inclined  backwards,  and  one  of  the  bones  had  been 
thrust  through  the  skin  on  the  front  of  the  arm. 

It  was  at  first  dressed  carefully  by  Dr.  Wilcox,  but  the  father  of  the 
lad  on  the  following  day  placed  him  under  the  care  of  an  empiric. 

Six  days  after  the  fracture  occurred,  I  was  called  to  see  him,  with 
several  other  gentlemen.  He  was  then  suffering  under  a  severe  attack 
of  tetanus  which  had  commenced  the  night  before.  His  arm  was  much 
swollen  and  very  painful.     He  died  the  same  evening. 

I  was  unable  to  learn  very  particularly  what  had  been  the  treat- 
ment since  the  patient  was  seen  by  Dr.  Wilcox,  except  that  the  band- 
ages had  been  most  of  the  time  very  tight,  and  that  the  empiric  had 
applied  stimulating  liniments,  the  boy  constantly  complaining  greatly 
of  the  pain.  I  found  the  arm  done  up  in  a  most  slovenly  manner  with 
several  narrow  splints,  underlaid  with  loose  and  knotty  fragments  of 
cotton-batting. 

We  removed  all  of  these  immediately,  and  laid  the  arm  upon  a 
cushion  supported  by  a  board,  to  both  of  which  the  arm  was  lightly 
secured  by  a  few  turns  of  a  bandage ;  cool  water  lotions  were  dili- 
gently applied,  and  chloroform  administered  by  inhalation  ;  but  the 
fatal  event  was  delayed  only  a  few  hours. 

I  shall  not  stop  to  inquire  the  cause  of  a  results©  unfortunate,  where 
the  treatment  has  been  so  palpably  unskilful. 

I  have  already  mentioned  one  case  of  gangrene  of  the  hand,  after 
a  fracture  of  the  lower  part  of  the  humerus;  Norris,  in  a  note  to  the 
American  edition  of  ListovLS  Surgery,  mentions  a  case  which  came 
under  his  observation  in  the  Pennsylvania  Hospital,  the  fracture  hav- 
ing taken  place  just  above  the  condyles,  and  still  another  has  been 
related  to  me  lately.  I  have  brought  together  also  no  less  than  six 
cases  of  sloughing  of  the  arm,  after  fracture  of  the  radius,  and  one  of 
sloughing  from  tight  bandaging,  where  the  radius  was  supposed  to  be 
broken,  although  the  dissection  proved  that  it  was  not. 

Robert  Smith  says  that  similar  cases  have  been  recorded  in  the 
Gazette  Medicale.  To  these  I  shall  now  add  five  examples  of  sloughing 
after  fracture  of  both  radius  and  ulna;  making  a  total  of  fifteen  cases 
in  the  upper  extremities,  in  addition  to  those  reported  in  the  Gazette 
Medicale,  an  exact  account  of  which  I  have  not  seen. 

John  McGrath,  set.  9,  fell,  July  2,  1847,  from  a  ladder,  about  thirty 
feet  to  the  ground,  breaking  the  right  radius  and  ulna  in  their  middle 
thirds.  A  surgeon  was  in  attendance  about  four  or  five  hours  after 
the  accident  occurred.  He  then  reduced  the  fractures  and  applied  two 
broad  splints,  one  on  the  palmar  and  one  on  the  dorsal  surface  of  the 
forearm.     Whether  a  roller  was  first  applied  to  the  arm  or  not,  I  am 


FRACTURES    OF    THE    RADIUS    AND    ULNA.  321 

unable  to  say.  The  splints  were  secured  in  place  by  a  roller  and  the 
arm  laid  in  a  sling. 

The  third  day  was  our  national  holiday,  and  the  patient  was  not 
visited.  Nor  was  he  seen  on  the  fourth  day,  not  being  found  at  home. 
On  the  fifth  day  the  surgeon  removed  the  bandages  and  found  the  arm 
gangrenous;  and  within  an  hour  afterwards  I  was  requested  to  see  it 
also. 

I  found  him  lying  in  a  miserable  apartment,  with  his  right  arm 
resting  upon  a  pillow.  The  arm,  forearm,  and  hand  were  gangrenous 
through  their  whole  extent;  and  the  skin  of  the  right  side,  on  the 
front  of  the  chest,  had  assumed  a  dusky  color,  the  extreme  margin  of 
which  was  indicated  by  an  abrupt  crescentic  line.  The  thumb  and 
fingers  were  black.  His  countenance  was  bright  and  cheerful,  and 
his  mind  intelligent;  pulse  75,  and  soft;  tongue  clean.  He  had  slept 
undisturbed  the  night  before,  and  he  had  all  along  felt  perfectly  well, 
except  that  he  had  a  slight  diarrhoea.  I  was  assured  by  the  surgeon, 
and  by  all  of  the  family,  that  the  bandages  had  not  been  applied 
tightly;  but  we  were  told  that  on  the  third  day  of  the  accident,  having 
been  locked  into  the  house  by  his  mother,  who  was  a  peddler,  he 
climbed  out  of  the  window,  and  that  during  all  of  that  and  most  of 
the  following  day  he  was  running  about  the  streets  firing  crackers, 
during  most  of  which  time  his  arm  was  removed  from  his  sling  and 
hanging  by  his  side.  On  the  morning  of  the  fourth  day  his  mother 
noticed  that  his  fingers  were  black,  but  she  thought  they  were  stained 
with  powder. 

We  ordered  him  to  take  one-quarter  of  a  grain  of  opium  every 
four  hours,  and  applied  a  yeast  poultice  to  the  arm.  On  the  seventh 
day  the  gangrene  was  still  extending,  and  the  pulse  was  124;  yet  he 
continued  to  feel  well  and  to  eat  as  usual.  On  the  tenth  day  the  line 
of  demarcation  had  commenced  opposite  the  shoulder-joint;  and  the 
crescentic  discoloration  on  the  breast,  which  had  at  first  spread  rapidly 
until  it  covered  nearly  the  whole  upper  half  of  the  chest,  was  quite 
faint,  in  some  parts  almost  lost. 

In  a  few  days  more  he  was  removed  to  the  county  almshouse,  the 
separation  continuing  rapidly  to  take  place  until  the  arm  fell  off  at 
the  shoulder-joint;  after  which  he  made  a  good  recovery. 

A  child,  two  years  and  three  months  old,  had  fallen  from  a  chair 
upon  the  floor,  a  distance  of  about  two  feet.  A  German  physician 
being  called,  found,  as  he  believes,  a  fracture  of  both  bones  of  the  left 
arm.  The  fracture  was  near  the  middle.  He  immediately  applied  a 
roller  from  the  fingers  to  the  elbow,  and  over  this  three  narrow  splints 
made  of  the  wood  of  a  cigar-box.  One  of  these  was  laid  upon  the 
palmar,  one  upon  the  dorsal,  and  one  upon  the  radial  side  of  the  fore- 
arm, and  the  whole  were  bound  together  by  another  roller.  From 
this  time  until  the  tenth  day  the  child  continued  to  play  about  on  the 
floor.  Ten  days  after  the  accident  occurred  the  doctor  noticed  that 
the  ulnar  side  of  the  little  finger  was  blue.  The  bandages  were  im- 
mediately removed,  and  were  never  again  applied  tightly. 

Three  or  four  days  after,  I  was  requested  to  see  the  arm  with  the 
attending  physician.    The  gangrene  had  continued  to  extend,  involving 


322  FEACTURES    OF    THE    RADIUS    AND    ULNA. 

now  the  whole  of  the  little  finger  and  most  of  the  thumb.  There  were 
also  gangrenous  spots  over  the  hand  and  forearm,  extending  to  within 
one  inch  from  the  elbow-joint;  these  spots  were  more  numerous  in 
front  and  on  the  back  of  the  forearm,  and  seemed  to  correspond  to 
the  pressure  of  the  splints.  The  hand  was  much  swollen,  and  also 
the  arm  above  the  line  of  the  gangrene.  The  sloughs  had  already 
commenced  to  be  thrown  off,  and  the  gangrene  was  only  extending  in 
a  few  points.  The  child  appeared  well  and  rather  playful,  except  when 
the  arm  was  being  dressed. 

I  ordered  a  yeast  poultice,  and  a  nourishing  diet. 

I  have  since  learned  that  the  arm  and  a  large  portion  of  the  hand 
were  finally  saved. 

About  the  year  1865,  as  near  as  I  can  remember,  a  lad  aged  about 
nine  years  was  brought  to  the  Long  Island  College  Hospital  Dis- 
pensary, with  a  fracture  of  the  radius  and  ulna.  It  was  dressed  by 
the  visiting  surgeon  with  splints  and  bandages.  He  did  not  return 
to  the  Dispensary  as  directed  to  do,  and  on  the  third  or  fourth  day 
portions  of  the  arm  and  hand  were  found  in  a  gangrenous  condition. 

Alice  Thompson,  get.  50,  was  admitted  into  my  service  at  Bellevue, 
March  16,  1870,  with  a  compound  fracture  in  the  lower  third  of  the 
forearm,  caused  by  a  fall  upon  the  hand  two  or  three  days  before 
admission.  The  hand  and  forearm  were  gangrenous.  She  said  it  was 
dressed  at  the  Dispensary,  immediately  after  the  receipt  of  the  injury, 
with  splints  and  bandages.  This  woman  died  about  the  seventh  day 
after  admission,  from  a  sudden  hemorrhage  induced  by  the  sloughing. 

In  March,  1867,  I  was  consulted  by  the  parents  of  D.  C,  of  Catta- 
raugus Co.,  N.  Y.,  on  account  of  a  serious  distortion  of  the  hand  and 
forearm,  caused  by  sloughing,  splints  and  bandages  having  been 
applied  by  her  surgeon  for  a  supposed  fracture ;  but  when  examined 
by  me  about  ten  weeks  after  the  accident,  there  was  no  evidence  that 
the  bones  had  ever  been  broken.  She  complained  to  her  surgeon  that 
the  bandages  were  too  tight,  but  he  thought  otherwise,  and  they  were 
not  removed  until  the  third  day,  when  the  gangrene  had  already 
occurred.     The  child  was  five  years  old  at  the  time  of  the  accident. 

South  also  says  that  he  has  seen  one  or  two  instances  of  m.ortifica- 
tion  produced  by  splints  applied  too  tightly,  and  previous  to  the  acces- 
sion of  the  swelling  after  fracture,  and  which  have  not  been  loosened 
as  the  swelling  increased.* 

How  shall  we  explain  the  frequency  of  these  accidents  after  fracture, 
especially  of  the  forearm  ? 

Malgaigne,  speaking  of  fractures  of  both  bones  of  the  forearm,  re- 
marks that  "when  the  displacement  is  considerable,  or  more  especially 
when  the  outward  violence  has  been  excessive,  we  frequently  see  follow 
a  very  intense  inflammatory  swelling,  and  there  is  no  fracture  which 
complicates  itself  so  easily  with  gangrene  under  the  pressure  of  appa- 
ratus."^ 

Says  Nelaton:  "If  we  make  choice  of  the  apparatus  of  J.  L.  Petit, 
it  is  necessary  that  it  shall  not  be  applied  too  tightly,  for,  as  Professor 

'  South,  note  to  Chelius's  Surg.,  vol.  i.  p.  69. 
2  Malgaigne,  Frac.  et  Disloc,  torn.  i.  p.  589. 


FRACTURES    OF    THE    RADIUS    AND    ULNA.  823 

Eoux  has  long  since  remarked,  fractures  of  the  forearm  are  those 
■which  furnish  most  of  the  examples  of  gangrene  in  consequence  of 
an  arrest  of  the  circulation.  This  is  easily  understood,  if  we  consider 
on  the  one  hand  the  superficial  position  of  the  two  principal  arteries 
of  the  forearm,  and  on  the  other  the  disposition  of  the  apparel,  which 
must  almost  infallibly  compress  the  arteries  to  a  great  extent."^ 

I  do  not  think  that  this  accident  is  due  always  to  the  negligence  of 
the  surgeon.  It  may  be  due  many  times  to  the  carelessness  of  the 
parents  or  of  the  patient  himself;  as  in  the  case  of  the  boy  who  came 
under  my  own  observation,  and  who  lost  his  arm  at  the  shoulder- 
joint.  Sometimes  also  it  may  be  due  rather  to  the  severity  of  the 
original  injury,  which,  the  experience  of  every  surgeon  will  prove,  is 
occasionally  competent  to  the  production  of  such  bad  results.  A 
number  of  unfortunate  circumstances  may  have  concurred,  such  as  a 
severe  injury,  especially  where  the  skin  has  remained  unbroken  and 
the  effused  IdIoocI  has  had  no  opportunity  to  escape — the  broken  bone 
may  have  rested  against  the  trunk  of  a  main  artery,  causing  an  arrest 
of  its  circulation — the  constitution  may  be  impaired  by  previous  ill- 
ness, or  it  may  be  suffering  under  the  shock  of  the  injury  ;  yet  that  it 
may  be  and  too  often  is  the  result  of  maltreatment,  on  the  part  of  the 
surgeon,  is  undeniable.  It  is  proper,  however,  to  discriminate  between 
the  responsibility  which  attaches  to  the  surgeon  as  the  true  exponent 
of  the  state  of  his  art,  and  that  which  attaches  to  the  art  itself  as 
taught  by  the  masters. 

The  old  surgeons  applied  first  a  roller  to  the  hand  and  forearm,  and 
over  this  their  various  splints.  J.  L.  Petit  thought  he  had  made 
a  valuable  improvement  upon  this  simple  plan  in  laying  over  the 
roller  a  compress,  supported  by  a  splint,  designed  to  press  between 
the  bones,  and  to  antagonize  thus  the  action  of  the  roller  in  drawing 
the  fragments  toward  each  other.  Duverney  believed  that  this  object 
would  be  best  accomplished  by  placing  the  pad  against  the  skin,  and 
under  a  circular  compress ;  while  Desault  declares  all  of  these  modes 
inefficient,  and  announces  a  method  which  he  regards  as  accomplishing 
at  once  and  completely  all  of  the  indications  ;  the  sole  peculiarity  of 
which  method  consists  in  placing  the  graduated  pads  against  the  skin, 
and  securing  them  in  place  by  a  roller.  Boyer  adopts  the  same  method 
without  any  modifications,  and  Mr.  Hind,  in  his  illustrations  of  frac- 
tures already  referred  to,  has  seen  fit  to  recommend  the  same,  at  least 
in  fractures  of  the  radius. 

It  is  quite  obvious  that  between  these  various  methods  there  remains 
very  little  if  anything  to  choose,  the  differences  being  too  trifling  and 
unessential  to  claim  serious  consideration.  Each  alike  is  inadequate 
to  accomplish  any  amount  of  useful  pressure  between  the  fragments  ; 
each  alike  is  calculated  to  bind  the  bones  one  against  the  other,  and 
each  alike  exposes  to  the  danger  of  ligation  and  of  gangrene. 

Says  M.  Dupuytren  :  "The  practice  of  rolling  the  arm  before  the 
splints  are  applied,  whether  internal  or  external  to  the  pads  and  com- 
presses, is  eminently  mischievous ;  and  instead  of  fulfilling,  directly 

'  Nelaton,  Pathologie  Chirurgicale,  p.  735. 


324  FRACTURES    OF    THE    RADIUS    AND    ULNA. 

counteracts,  the  indications  whicli  it  is  most  important  to  keep  in  view 
in  the  treatment  of  fractures  of  the  forearm." 

And  notwithstanding  the  same  sentiment  has  been  reiterated  by 
Velpeau,  Malgaigne,  Nelaton.  Samuel  Cooper,  Bransby  Cooper, 
Erichsen,  Amesbury,  Gibson,  and  others,  yet  we  find  to-day  the  great 
surgeon  of  Heidelberg,  Chelius,  recommending  the  roller  to  be 
applied  under  the  splints,  after  the  manner  of  Desault;  while  Liston, 
Syme,  and  Fergusson,  who  perhaps  represent  the  Edinburgh  school, 
use  only  pasteboard  splints  above  the  compresses,  over  which  is  im- 
mediately applied  the  roller ;  a  practice  which  differs  very  little  from 
that  recommended  by  Desault,  and  is  equally  obnoxious  to  criticism. 

Among  the  American  surgeons,  I  believe,  the  advice  and  practice 
of  Dupuytren  have  received  almost  universal  assent,  only  that  we  have 
always  employed  splints  much  wider  than  those  recommended  by 
this  distinguished  surgeon.  I  cannot  therefore  agree  with  my  accom- 
plished countryman,  Dr.  Reynell  Coates,  if  in  the  following  para- 
graph he  means  to  imply  that  American  surgeons  generally  adopt 
Desault's  treatment.  Such  at  least  is  not  my  experience.  "It  would 
be  wrong,"  says  Dr.  Coutes,  "  not  to  bear  testimony,  on  every  possible 
occasion,  against  the  folly  so  universally  prevalent,  that  induces 
surgeons  to  apply  a  bandage  directly  to  the  forearm  before  applying 
splints  in  injuries  of  this  character.  We  have  often  asked  for  a  ra- 
tional explanation  of  this  practice,  without  effect.  It  is  directly  at 
war  with  the  acknowledged  indications  in  the  coaptation  of  the  frag- 
ments, and  when  the  object  of  the  whole  apparatus  is  to  thrust 
asunder  their  extremities,  it  commences  by  binding  them  together. 
Few  plans  in  surgery  are  more  generally  followed ;  none  can  be  more 
absurd," 

Of  the  estimate  placed  upon  the  roller  by  M.  Mayor,  the  reader 
will  judge  by  a  reference  to  the  passage  which  I  shall  quote  further 
on,  when  I  shall  speak  of  the  value  of  the  interosseous  compresses. 

Amesbury  and  Bransby  Cooper  use  no  rollers  at  all — not  even  to 
secure  the  splints  in  place,  they  being  made  fast  to  the  forearm  by 
straps  or  tapes. 

Mr.  Amesbury  and  Mr.  South  also  endeavor  to  give  to  their  splints 
an  appropriate  shape,  by  having  them  constructed  with  more  or  less 
convexity.  It  must  be  noticed,  however,  that  the  practice  of  these 
two  gentlemen  is  very  dissimilar,  for  while  Mr.  South  applies  the 
convex  surface  of  his  splint  to  the  interosseous  space,  Mr.  Amesbury 
reverses  this  plan,  and  applies  the  concave  surface  directly  to  the  skin. 

As  to  the  width  of  the  splints,  surgeons  are  also  very  generally 
agreed,  at  the  present  day,  that  they  ought  to  be  wider  than  the  arm, 
so  as  to  prevent  the  roller  or  the  tapes  from  resting  against  its  sides. 

I  do  not  intend  to  deny  peremptorily,  and  without  qualification,  the 
value  of  the  graduated  compresses,  which,  as  we  have  seen,  are  usually 
laid  along  the  interosseous  space  to  press  the  fragments  asunder.  It 
is  necessary,  however,  to  caution  the  surgeon  against  their  injudicious 
use.  M.  Nelaton  has  well  remarked  of  the  apparel  employed  by  J. 
L.  Petit,  that  it  must  inevitably  compress,  to  a  great  extent,  the 
arteries  of  the  forearm ;  and  the  remark  is  applicable,  in  only  a  less 


I 


FEACTURES    OF    THE    RADIUS    AND    ULNA.  825 

degree,  to  all  of  those  other  plans  in  which  the  compress  is  employed. 
And  I  suspect  that  to  this  portion  of  the  dressing,  quite  as  much  as  to 
any  other  cause,  are  due  those  frightful  accidents  of  which  we  have 
already  spoken.  The  arteries  are  not  only  exposed,  from  their  super- 
ficial position,  to  pressure  from  a  compress,  but,  in  addition  to  this,  it 
will  be  noticed  that  the  two  principal  arteries,  the  radial  and  the  ulnar, 
are  situated  upon  a  broad  and  flat  surface  of  bone,  along  which  this 
pressure  must  operate  most  advantageously.  So  early  as  the  year 
1833,  M.  Lenoir,  in  his  inaugural  thesis  at  Paris,  called  attention  to 
this  danger,  and  from  time  to  time  surgeons  have  continued  to  advert 
to  it,  but  they  have  seldom  given  to  its  consideration  that  prominence 
which  its  importance  deserves. 

I  have  observed  another  fact  in  this  connection  :  when  this  compress 
is  extended  low  down  on  the  palmar  surface,  within  an  inch  or  two  of 
the  wrist-joint,  it  soon  becomes  excessively  painful,  and  sometimes 
even  wholly  insupportable,  in  consequence  of  the  pressure  made  upon 
the  median  nerve  ;  and  I  find  myself  always  obliged  to  exercise  great 
care  in  the  adaptation  of  the  pads  at  this  point.  For  this  reason  alone, 
I  believe,  in  case  of  a  fracture  near  the  base  of  the  radius,  the  lower 
fragment,  if  it  were  thrown  toward  the  ulna,  could  not  be  retained  in 
its  place  by  graduated  compresses. 

In  short,  finding  that  broad  splints,  properly  covered  and  padded, 
answer  very  well  to  crowd  the  muscles  into  the  interosseous  space,  so 
far  as  it  is  proper  to  do  so,  and  believing  that  this  mode  is  less  painful 
and  less  dangerous,  I  seldom  resort  to  graduated  compresses,  nor  can 
I  appreciate  their  necessity,  or  indeed  their  utility.  Mr.  Lonsdale 
also  concurs  with  me  in  attaching  very  little  value  to  this  part  of  the 
accustomed  apparel. 

But  listen  to  the  surgeon  of  Lausanne,  M.  Mayor:  "AVhat  signify 
graduated  compresses  placed  between  the  bones  of  the  forearm  for 
the  purpose  of  separating  them  from  each  other?  These  bones  will 
not  have  that  constant  tendency  to  approach  each  other  which  has 
been  supposed,  provided,  first,  that  they  have  been  well  reduced  ; 
second,  that  for  the  purpose  of  maintaining  them  in  position  we  do 
not  make  use  of  a  preliminary  circular  bandage,  whose  action  is  an 
absurdity  j  and,  in  short,  provided  we  make  the  retentive  means  act 
chiefly  upon  the  palmar  and  dorsal  surfaces  of  the  forearm."^ 

M.  Mayor  proceeds  to  declare  these  convictions  to  be  the  result  of 
his  own  experience,  both  in  the  treatment  of  simple  and  compound 
fractures  of  the  forearm,  and  he  intimates  that  in  the  use  of  the  cir- 
cular bandage  with  compresses,  surgeons  seem  to  have  rolled  the  arm 
into  a  cylinder  and  drawn  the  bones  together,  in  order  that  they  might 
tax  their  ingenuity  to  discover  some  means  to  again  separate  them. 

Surgeons  have  generally,  after  the  splints  have  been  applied,  placed 
the  forearm  in  a  position  of  semi-pronation,  or  midway  between  su- 
pination and  pronation,  so  that  the  radius  should  be  uppermost ;  it 

'  Bandages  et  Appareils  a  Pansements,  ou  Nouveau  Systeme  de  Deligation  Chi- 
rurgicale,  par  M.  Mathias  Mayor,  Chirurg.  en  Chef  de  rilopital  de  Lausanne, 
Switzerland.     Paris  ed.  1838,  p.  345. 


326       FRACTURES  OF  THE  RADIUS  AND  ULNA. 

being  assumed  that  in  this  position  the  two  bones  are  most  nearly  par- 
allel, and  least  inclined  to  displacement.  Such,  indeed,  was  the  prac- 
tice of  Hippocrates,  Paulus  ^gineta,  Celsus,  Albucasis,  and  of  most 
surgeons  down  to  this  day  ;  but  Lonsdale,  Eobert  Smith,  Nelaton,  and 
South  have  lately  called  in  question  the  correctness  of  this  mode  of 
dressing,  at  least  when  it  is  adopted  as  a  universal  rule. 

I  have  before  mentioned,  when  treating  of  fractures  of  the  ulna, 
that  M.  Fleury  had,  in  one  instance,  been  unable  to  bring  the  frag- 
ments into  apposition  except  by  forced  supination  of  the  forearm ; 
and  in  certain  fractures  we  have  seen  the  same  position  recommended 
by  Lonsdale. 

Says  Mr.  South,  in  a  note  to  Chelius :  "  In  fractures  of  both  bones 
the  forearm  is  best  laid  supine;"  and  Nelaton  declares  that  in  frac- 
tures of  the  radius  and  ulna  at  any  point  of  their  upper  thirds  it  will 
be  necessary  to  supine  the  arm,  both  in  the  reduction  and  during  the 
subsequent  treatment;  but  that  in  fractures  of  the  inferior  two-thirds 
we  may  place  the  limb  in  a  condition  of  semi-pronation. 

It  seems  very  probable,  however,  that  both  of  these  gentlemen  have 
received  their  suggestions  from  Mr.  Lonsdale,  who,  as  we  have  already 
seen,  has  treated  the  question  very  much  at  length,  and  who  has  finally 
declared  his  decided  preference  for  the  supine  position  in  the  treatment 
of  all  fractures  of  the  forearm.  His  arguments  are  certainly  very  in- 
genious, and  as  applied  to  fractures  of  the  radius  above  the  insertion  of 
the  pronator  radii  teres,  they  seem  altogether  conclusive  ;  and,  indeed, 
they  commend  themselves  very  strongly  to  our  judgment,  as  applied 
to  all  fractures  of  the  forearm.  They  are  sustained  also  by  the  results 
of  his  own  experience,  and  I  see  no  good  reason  why  they  should  not 
be  more  thoroughly  examined  and  tested  by  other  surgeons.  The 
advantages  which  he  claims  for  this  method  are  more  perfect  coapta- 
tion of  the  broken  ends,  less  liability  of  the  fragments  to  encroach 
upon  the  interosseous  space,  and  consequently  less  danger  of  anchy- 
losis between  the  bones  and  of  non-union  of  the  fragments,  more 
complete  restoration  of  the  power  of  supination,  and  less  tendency  to 
lateral  distortion,  or  of  falling  off  to  the  ulnar  or  radial  sides. 

My  own  cases,  treated  by  the  usual  method,  have  shown  that  while 
supination  is  frequently  impaired,  and  sometimes  entirely  lost,  prona- 
tion is  rarely  affected;  and  that  lateral  displacements  are  much  more 
common  than  displacements  forwards  or  backwards.  How  this  posi- 
tion, semi-pronation,  may  tend  to  the  production  of  a  permanent  pro- 
nation, I  have  fully  explained  when  speaking  of  fractures  of  the  head 
of  the  radius;  and  the  influence  of  the  same  position,  the  forearm 
resting  upon  its  ulnar  margin  in  the  sling,  in  the  production  of  a 
lateral  deviation,  is  also  easily  understood.  If  the  arm  rests  upon  the 
sling  so  that  its  weight  bears  more  upon  the  point  of  fracture  than 
upon  the  extremities  of  the  bones,  then  the  ulna,  or  both  ulna  and 
radius,  will  incline  gradually  to  the  radial  side,  and  the  hand  will  fall 
off  to  the  ulnar  side ;  or  if  the  sling  rests  under  the  wrist  or  hand 
chiefly,  the  hand  will  ascend  to  the  radial  side,  and  the  broken  ends 
of  the  two  bones  will  project  to  the  ulnar  side. 

If  this  plan  is  adopted,  viz.,  laying  the  hand  and  forearm  upon  its 


FRACTUEES    OF    THE    CAEPAL    BONES.  327 

back,  instead  of  upon  its  ulnar  margin,  the  elbow  should  remain  at 
the  side,  the  humerus  falling  perpendicularly  from  its  socket;  and 
the  forearm  should  rest  in  the  sling  directed  forwards  from  the  body. 

Finally,  whatever  may  be  the  mode  of  dressing,  let  me  repeat  the 
injunction  to  examine  the  arm  frequently.  No  surgeon  can  do  justice 
to  himself,  or  to  his  patient,  who  does  not  look  at  the  arm  at  least 
once  in  twenty-four  hours  during  the  first  ten  or  fourteen  days,  and 
in  some  cases  the  patient  ought  to  be  seen  twice  daily. 

When  the  fracture  is  compound,  it  is  often  quite  impossible  to 
retain  the  forearm  in  the  half-pronated  position  ;  since,  when  thus 
placed,  and  only  slightly  supported,  as  it  must  necessarily  be,  it  in- 
evitably falls  over  upon  its  palmar  surface. 

There  can  be  no  doubt  that  in  such  a  case  we  ought,  from  the  first, 
if  it  is  found  practicable,  to  place  it  upon  its  back,  in  a  position  of 
complete  or  nearly  complete  supination.  For  this  purpose,  a  single 
broad  splint,  carefully  cushioned,  and  covered  with  oiled  cloth,  is  the 
most  suitable.  Upon  this  the  forearm  is  to  be  laid,  and  secured  gently 
with  a  few  turns  of  the  roller.  If  the  patient  is  able  to  do  so,  and 
wishes  to  walk  about,  the  board  may  be  suspended  to  the  neck,  as 
recommended  by  M.  Mayor. 

I  have  said  that  we  ought,  in  cases  of  compound  fracture,  to  lay  the 
forearm  upon  its  back,  if  practicable.  I  am  sure,  however,  that  the 
surgeon  will  find  very  many  patients  who  cannot  endure  this  position, 
and  he  may  be  compelled,  therefore,  to  lay  the  limb  upon  its  palmar 
surface,  or  to  leave  it  to  assume  any  other  position  in  which  it  may 
be  the  most  at  ease.  In  conclusion,  I  desire  again  to  call  attention  to 
the  splint  employed  by  Dr.  Scott,  and  of  which  an  illustration  is  given 
in  the  chapter  which  treats  of  fractures  of  the  radius. 


CHAPTER    XXIV. 

FRACTURES  OF  THE  CARPAL  BONES. 

The  few  cases  of  fracture  of  the  carpal  bones,  which  have  come 
under  my  observation  were,  without  exception,  compound  and  com- 
plicated, and  have  resulted  in  the  complete  loss  of  the  hand,  or  in 
some  less  serious,  but  never  inconsiderable,  mutilation  or  maiming. 

In  no  case  has  a  treatment  been  adopted  which  might  be  regarded 
as  having  reference  to  the  fracture,  or  the  purpose  of  which  was  to 
insure  apposition  and  union  of  the  fragments. 

It  may  be  proper  to  assume  in  a  matter  so  easily  comprehended, 
what  actual  and  recorded  experience  has  not  proven,  namely,  that 
simple  fractures  of  these  bones  will  demand  very  little  surgical  inter- 
ference, and  that  they  will  unite  generally  without  much  displacement, 
and  without  any  considerable  maiming.  It  is,  indeed,  quite  probable 
that  some  degree  of  anchylosis  between  their  adjacent  surfaces  will 


828      FRACTUEES  OF  THE  METACARPAL  BONES. 

occur,  yet  even  in  the  normal  condition  they  enjoy  so  little  motion  as 
to  render  it  doubtful  whether  its  complete  loss  would  be  very  sensibly 
felt. 

In  cases  of  comminuted,  compound,  and  otherwise  complicated  frac- 
tures of  the  carpal  bones,  which  accidents  are  sufficiently  common, 
the  surgeon  has  only,  I  conceive,  to  follow  carefully  those  general  or 
special  indications  which  may  happen  to  be  present,  the  precise 
character  of  which  it  would  be  difficult  to  anticipate,  and  for  the  treat- 
ment of  which  it  would  be  unsafe  to  attempt  in  a  written  treatise  to 
provide. 


CHAPTER    XXV. 

FRACTURES  OF  THE  METACARPAL  BONES. 

Development  of  Metacarpal  Bones. — These  bones  are  each  formed 
from  two  centres  of  ossification.  In  the  case  of  the  metacarpal  bones 
of  the  four  fingers  there  is  one  centre  for  each  shaft,  and  one  for  each 
distal  extremity  ;  but  in  the  case  of  the  metacarpal  bone  of  the  thumb 
there  is  one  centre  for  the  shaft  and  one  for  the  proximal  extremity. 
All  these  epiphyses  unite  with  the  shafts  at  about  the  twentieth  year. 

Causes. — These  bones,  also,  are  generally  broken  by  direct  blows  ; 
and  in  that  case  the  injury  is  often  of  such  a  character  as  to  demand 
amputation,  and  does  not  therefore  belong  to  that  class  of  accidents 
of  which  it  is  the  purpose  of  this  volume  to  treat.  Not  an  incon- 
siderable number,  however,  are  the  results  of  indirect  blows,  and  es- 
pecially of  blows  upon  the  knuckles  received  in  pugilistic  encounters. 
Thus,  in  a  record  of  fourteen  fractures,  I  find  this  cause  assigned  in 
six ;  in  one  other  instance  it  was  occasioned  by  falling  upon  the  clenched 
fist,  and  in  one  by  striking  a  board  ;  so  that  the  fracture  has  resulted 
from  a  blow  upon  the  ends  of  the  bones  in  eight  of  the  fourteen 
examples. 

Point  of  Fracture ;  Direction  of  Displacement ;  Symptoms. — Once  the 
fracture  has  occurred  in  the  metacarpal  bone  of  the  thumb ;  six 
times  in  the  metacarpal  bone  of  the  index  finger ;  once  in  the  second 
finger  ;  three  times  in  the  ring  finger,  and  three  times  in  the  metacar- 
pal bone  of  the  little  finger.  Two  of  those  belonging  to  the  ring  finger, 
and  the  three  occurring  in  the  little  finger,  were  produced  by  blows 
with  the  clenched  fist,  and  in  each  instance  the  fracture  was  in  the 
lower  or  distal  third  of  the  bone.  Two  of  the  fractures  of  the  meta- 
carpal bone  of  the  index  finger  were  produced  also  in  the  same  way; 
but  the  fractures  were  near  the  middle  of  the  bone.  Of  the  whole 
number,  six  were  broken  through  the  lower  third,  five  through  the 
middle,  and  three  through  the  upper  third. 

In  every  instance  where  the  bone  is  known  to  have  been  broken  by 
a  blow  upon  the  knuckles,  the  distal  end  of  the  distal  fragment  was 


FRACTURES  OF  THE  METACARPAL  BONES.      329 

thrown  toward  the  palm,  and  this  fragment  was  salient  backwards  at 
the  point  of  fracture. 

In  the  following  case  the  bone  was  probably  separated  at  the 
epiphysis. 

Thomas  Eose,  set.  8,  fell  down  a  flight  of  steps,  Sept.  11,  1855, 
breaking  the  metacarpal  bone  of  the  index  finger  of  the  right  hand 
near  its  lower  extremity,  and  apparently  at  the  junction  of  the  epi- 
physis with  the  diaphysis. 

I  saw  the  lad  about  sixteen  hours  after  the  accident.  The  lower 
fragment,  projecting  abruptly  into  the  palm  of  the  hand,  could  be 
easily  replaced,  or  with  only  moderate  effort,  yet  immediately  when 
the  support  was  removed  it  would  become  displaced.  There  was  no 
crepitus. 

It  was  dressed  very  carefully  with  a  splint  and  compress ;  but 
notwithstanding  our  continued  efforts  to  keep  the  fragments  in  place, 
the  epiphysis  united  considerably  depressed  toward  the  palm. 

In  one  instance,  also,  I  think  the  bone  was  rather  bent,  or  partially 
fractured,  than  broken  completely.  This  was  the  case  of  fracture  of 
the  metacarpal  bone  of  the  ring  finger,  produced  in  a  gymnasium  by 
striking  with  the  clenched  fist  against  a  board,  and  to  which  I  have 
already  alluded.  I  did  not  see  the  young  man  until  four  weeks  after 
the  accident,  when  I  found  the  lower  end  of  the  bone  depressed  toward 
the  palm,  and  the  angle  made  at  the  point  of  fracture  was  rather 
rounded  and  quite  smooth ;  it  was  also  tender  at  this  point,  but  the 
bone  was  firm  and  unyielding.  Four  years  after  I  was  permitted  to 
examine  it  again,  and  I  found  the  same  slight  deformity  still  con- 
tinuing. 

A  partial  explanation  of  the  fact  that  the  distal  end  of  the  distal  frag- 
ment is  generally  displaced  toward  the  palm,  may  be  found  in  the 
natural  curve  of  these  bones,  which  is  such  that  when  the  fracture  has 
been  produced  by  a  counter-stroke,  the  distal  end  would  almost  neces- 
sarily be  driven  in  this  direction;  and  a  farther  explanation  has  been 
suggested  by  Mr.  B.  Cooper,  namely,  the  action  of  the  interossei. 

Results. — Generally,  when  the  fracture  is  simple,  and  the  displace- 
ment is  not  considerable,  the  nature  of  the  accident  is  overlooked,  and 
some  deformity  must  inevitably  ensue.  In  a  majority  of  the  cases 
which  have  come  under  my  observation  this  has  been  the  fact,  and 
the  bone  has  remained  slightly  bent  at  the  seat  of  fracture,  but  with- 
out affecting  in  any  degree  the  value  of  the  hand. 

The  following  example  has  furnished  the  most  serious  result  of 
any  case  of  simple  fracture  of  these  bones  which  has  come  under  my 
notice. 

Louis  Mooney,  set.  25,  struck  a  man  with  his  clenched  fist,  Nov.  4, 
1856,  breaking  the  metacarpal  bone  of  the  index  finger  of  the  right 
hand,  near  its  middle.  Great  swelling  and  suppuration  followed  the 
injury. 

February  21,  1857,  nearly  four  months  after  the  injury  was  re- 
ceived, he  consulted  me.  There  existed  at  this  time  a  complete  anchy- 
losis at  the  wrist-joint,  and  partial  anchylosis  in  the  fingers.  The  hand 
was  deflected  forcibly  to  the  radial  side.  At  the  point  of  fracture  the 
22 


830      FKACTURES  OF  THE  METACARPAL  BONES. 

fragments  were  salient  backwards  and  quite  prominent,  but  firmly 
united. 

Even  when  the  existence  of  the  fracture  is  recognized,  it  is  not 
always  easy  to  retain  the  fragments  in  place,  as  the  case  of  epiphyseal 
separation  already  mentioned,  and  the  following  case,  will  illustrate. 

Miss  E.,  of  Erie  Co.,  K  Y.,  set.  18,  fell,  Aug.  7, 1853,  striking  upon 
her  right  hand  with  her  fingers  forcibly  bent  into  the  palm  of  the 
hand.  On  the  following  day  she  consulted  me  at  my  office,  and  I 
found  the  metacarpal  bone  of  the  ring  finger  broken  about  three- 
quarters  of  an  inch  from  its  distal  end,  and  the  distal  extremity  of 
the  fragment  depressed  toward  the  palm.  A  feeble  crepitus,  with 
distinct  motion,  completed  the  diagnosis.  The  young  lady  was  very 
anxious  to  have  a  perfect  hand,  and  I  was  determined  if  possible  to 
accomplish  it.  Finding  that  the  joint-end  of  the  distal  fragment  was 
constantly  disposed  to  fall  toward  the  palm,  I  constructed  a  gutta- 
percha splint  for  the  hand  and  fingers,  and  after  placing  a  pad  directly 
underneath  this  fragment,  I  secured  it  firmly  with  a'  roller.  From 
this  time  until  the  end  of  four  weeks  she  remained  under  my  care, 
visiting  me  as  often  as  once  or  twice  a  week;  and  at  each  dressing  I 
found  the  distal  fragment  slightly  displaced  in  the  same  direction 
as  at  first,  nor  was  I  able  ever  to  make  it  resume  completely  its 
position. 

Ordinarily,  however,  no  such  difficulty  is  experienced,  and  the  bone, 
supported  by  such  simple  means  as  we  shall  presently  direct,  unites 
quickly  and  without  deformity. 

An  engineer  was  struck  by  a  piece  of  iron  in  such  a  way  as  to  break 
his  right  forearm  and  the  second  metacarpal  bone  of  the  same  hand. 
The  fracture  of  the  metacarpal  bone  was  compound  and  about  three- 
quarters  of  an  inch  from  its  proximal  extremity.  When  he  called 
upon  me,  which  was  immediately  after  the  injury  was  received,  I 
found  the  proximal  fragment  projecting  directly  backwards,  its  sharp 
point  rising  above  the  skin;  into  which  position  it  was  evidently 
drawn  by  the  action  of  the  extensor  carpi  radialis  longior  muscle. 
By  pressure  alone  it  could  be  replaced,  but  it  was  much  more  easily 
reduced  when  the  hand  was  forcibly  carried  backwards  on  the  fore- 
arm. I  therefore  secured  the  hand  in  this  position  with  appropriate 
splints,  and  it  was  maintained  in  this  posture  during  most  of  the  sub- 
sequent treatment.  Union  finally  took  place,  but  not  without  some 
backward  displacement.  Four  months  after  the  accident  occurred,  on 
the  31st  of  December,  1858,  I  examined  the  hand,  and  found  the  skin 
healed  over  completely,  the  end  of  the  fragment  having  become 
rounded  and  smooth,  so  as  not  to  give  him  any  degree  of  annoyance. 
His  wrist  was  as  flexible  and  as  strong  as  before.  No  doubt  the  pro- 
jection of  the  fragment  might  have  been  prevented  entirely  by  cutting 
at  the  point  of  its  attachment  the  tendon  of  the  extensor  muscle,  but 
this  would  have  sensibly  weakened  the  wrist-joint,  and  I  preferred  the 
alternative  of  a  projection  of  the  fragment. 

Treatment. — With  moderate  extension  made  upon  the  finger  cor- 
responding to  the  broken  bone,  while  the  fragments  are  forced  home 
by  firm  pressure,  the  bone  may  generally  be  brought  at  once  into  line, 


FEACTUEES    OF    THE    FINGEES.  331 

and  we  may  now  proceed  to  adapt  a  gutta-percha,  felt,  or  thick  paste- 
board splint,  to  either  the  whole  surface  of  the  back  or  palm  of  the 
hand  and  fingers,  while  they  are  held  in  a  position  of  easy  flexion. 
It  is  not  very  material  to  which  of  these  surfaces  the  splint  is  applied; 
or  rather,  I  may  say,  it  ought  to  be  applied  to  the  one  or  the  other 
according  as  circumstances  seem  to  indicate.  It  should  be  well  pad- 
ded, and  especially  at  certain  points,  in  order  to  the  more  effectual 
support  of  the  fragments.  It  is  then  to  be  secured  in  place  with 
several  turns  of  a  roller.  When  either  of  the  metacarpal  bones,  ex- 
cept those  of  the  great  or  ring  finger,  is  broken,  the  splint  must  be 
wide  enough  to  secure  the  sides  of  the  hand  against  the  pressure  of 
the  roller. 

Thus  dressed,  the  hand  may  be  laid  in  a  sling  beside  the  chest,  or 
while  sitting  it  may  rest  upon  a  table. 

The  apparel  must  be  examined  daily,  and  readjusted  as  often  as  it 
shall  become  disarranged,  or  as  a  doubt  shall  arise  as  to  the  condition 
of  the  parts. 

When  the  fracture  is  followed  by  much  inflammation,  or  occurs 
near,  and  especially  if  it  actually  involves  a  joint,  the  same  precau- 
tions must  be  adopted  to  prevent  anchylosis  as  in  the  case  of  similar 
fractures  in  other  bones. 


CHAPTER   XXVI. 

FRACTURES  OF  THE  FINGERS. 

Development  of  the  Phalanges  of  the  Hand. — The  phalanges  of  the 
hand  are  formed  from  two  centres  of  ossification,  namely,  one  for  each 
shaft  and  one  for  each  proximal  end.  Ossification  commences  in  the 
shafts  at  about  the  sixth  week ;  in  the  epiphyses  of  the  first  phalanges 
between  the  third  and  fourth  years,  and  in  the  epiphyses  of  the  two 
last  phalanges  somewhat  later.  Complete  bony  union  takes  place 
between  the  epiphyses  and  the  shafts  at  from  the  eighteenth  to  the 
twentieth  year. 

Causes. — I  do  not  remember  to  have  seen  a  fracture  of  one  of  the 
phalanges  produced  by  a  counter-stroke;  I  am  aware,  however,  that 
they  are  occasionally  produced  in  this  way,  as  by  falling  upon  the 
ends  of  the  fingers,  and  especially  by  the  stroke  of  a  ball  in  the  game 
of  base. 

The  fact,  however,  that  they  are  generally  the  consequence  of  a 
direct  blow,  and  that  the  finger  bones  are  small  and  only  protected  by 
a  thin  covering  of  skin  and  tendons,  renders  them  peculiarly  liable  to 
comminution  and  to  other  serious  complications.  Thus,  in  a  record 
of  thirty  fractures,  only  eighteen  were  sufficiently  simple  to  warrant 
an  attempt  to  save  them  ;  and  only  five  are  recorded  as  simple  frac- 
tures without  complications. 

Point  of  Fracture  and  Direction  of  Displacement. — In  the  following 


332  "  FRACTUEES    OF    THE    FINGERS. 

case  there  was  probably  an  epiphyseal  disjunction.  A  lad  four  years 
old  was  admitted  to  the  Hospital  of  the  Sisters  of  Charity,  Dec.  24, 
1849,  with  a  simple  fracture  of  the  first  phalanx  of  the  ring  finger  of 
the  left  hand  ;  the  fracture  being  at  the  proximal  end  of  the  bone,  and 
at  the  junction  of  the  epiphysis  with  the  shaft. 

The  finger  was  so  much  swollen  at  first,  that  no  dressings  were 
applied  until  the  fifth  day,  at  which  time  a  gutta-percha  splint  was 
moulded  to  it  carefully.     It  resulted  in  a  perfect  cure. 

I  have  never  seen  the  fragments  much  overlapping,  except  in  one 
instance.  Frequently  there  has  been  no  perceptible  displacement 
whatever;  but  generally  there  will  be  found  a  slight  displacement 
in  the  direction  of  the  diameter  of  the  bone. 

The  case  to  which  I  refer  as  presenting  an  extraordinary  overlapping, 
was  that  of  an  Irish  laboring  woman,  aged  about  thirty-five  years, 
who,  having  fallen  down  a  flight  of  steps,  broke  the  first  phalanx  of 
the  thumb  below  its  middle.  Dr.  Congar  was  first  called  on  the  day 
following  the  accident,  but  was  unable  to  reduce  the  fracture,  and  on  the 
same  day  invited  me  to  see  the  patient  with  him.  The  distal  fragment 
was  displaced  backwards,  overlapping  the  proximal  fragment  a  little 
more  than  one-quarter  of  an  inch.  We  made  repeated  efforts,  by 
pulling  upon  the  thumb  with  a  sliding  noose,  and  with  all  the 
strength  of  our  four  hands,  but  to  no  purpose.  The  fragments  could 
not  be  reduced  for  one  moment ;  and  we  left  the  patient  as  we  had 
found  her,  only  somewhat  the  worse  for  our  violent  and  repeated 
extensions  and  manipulations.  The  finger  was  already  considerably 
swollen  when  we  began  our  efforts,  and  we  cannot  therefore  say  what 
might  have  been  accomplished  at  an  earlier  moment,  but  I  confess 
that  our  defeat  was  unexpected,  and  does  not  seem  to  me  to  be  satis- 
factorily explained. 

Results. — At  least  ten  have  left  no  appreciable  lameness  or  deform- 
ity, and  possibly  several  more.  It  is  therefore  probably  true  that 
these  consequences  may  be  avoided  with  proper  care  in  one  half  of 
the  examples  in  which  we  attempt  to  save  the  finger;  and  perhaps  it 
will  occasion  surprise  that  a  perfect  result  may  not  be  claimed  in  a 
larger  proportion ;  but  when  we  consider  how  frequently  the  accident 
is  compound,  and  that  even  when  it  is  not,  the  blow  having  generally 
been  received  directly  upon  the  point  of  fracture,  how  promptly 
swelling  ensues,  it  will  be  easily  understood  that  it  will  be  often  found 
difficult  to  determine  whether  the  bone  is  exactly  in  line  or  not,  or  to 
maintain  it  in  this  position  after  absolute  coaptation  has  been  once 
secured. 

I  have  seen  the  finger  in  two  or  three  cases  deviate  laterally,  or 
become  permanently  deflected  to  one  side  or  the  other ;  and  once  I 
have  found  it  united,  but  rotated  on  its  own  axis.  This  latter  case  is 
not  without  instruction. 

A  girl,  aet.  6,  had  her  little  finger  caught  by  a  door  violently  shut, 
breaking  one  of  the  phalanges,  and  nearly  severing  the  finger.  I 
closed  the  wound,  and  dressed  the  finger  with  a  moulded  pasteboard 
splint.  My  dressings  were  repeated  often,  and  applied  carefully  ;  nor 
did  I  detect  the  rotation  which  the  lower  fragment  had  made  upon  its 


FRACTURES    OF    THE    FINGERS.  333 

own  axis  until  tlie  union  was  consummated.  I  then  found  the  ex- 
tremity of  the  finger  turned  so  that  its  palmar  surface  presented 
diagonally  toward  the  ring  finger. 

If  the  surgeon  believes  that  this  ought  to  have  been  prevented,  and 
that  the  result  evinces  a  lack  of  skill  or  of  care,  its  record  may  still 
serve  one  of  the  purposes  for  which  it  was  designed,  and  secure  to  the 
patient  sometimes  hereafter  more  faithful  and  assiduous  attention. 

Treatment. — Boyer,  and  after  him  Bransby  Cooper,  have  taught  that 
when  the  extreme  phalanx  is  broken,  from  the  small  size  of  the  bone, 
and  from  its  having  attached  to  it  the  nail  and  its  matrix,  it  is  better 
in  all  cases  to  amputate  at  once,  as  the  process  of  reparation  is  in  such 
case  extremely  slow  and  uncertain. 

Whether  in  any  of  the  cases  treated  by  myself,  or  which  have  been 
seen  by  me,  the  fracture  involved  the  last  phalanx,  I  am  not  now  able 
to  say,  but  my  impression  is  that  such  cases  have  come  under  my 
notice  which  have  been  successfully  treated,  and  I  cannot  but  regard 
the  rule  established  by  these  gentlemen  as  much  too  stringent.  Ex- 
amples must,  no  doubt,  sometimes  occur,  in  which  the  fracture  is  so 
simple  in  its  character  as  to  render  prompt  reunion  pretty  certain; 
and  even  though  the  restoration  should  prove  tedious,  this  ought 
scarcely  to  be  regarded  as  a  sufficient  justification  for  so  serious  a 
mutilation  as  these  surgeons  propose,  since  the  loss  of  even  an  extreme 
phalanx  is  not  only  a  deformity,  but  must  prove  in  many  occupations 
a  troublesome  maiming. 

Prof.  J.  Lizars,  of  the  Toronto  school  of  medicine,  C.  W.,  has  re- 
ported to  me  a  case  exactly  in  point.  "  A  man  in  the  employ  of  the 
Toronto  Rolling  Mills  Company  fractured  the  distal  extremity  of  the 
ring  finger  of  the  right  hand.  The  fracture  was  transverse,  and  the 
nail  was  severely  bruised,  the  accident  being  caused  by  a  direct  blow. 
Crepitus  distinct.  A  dorsal  splint  and  bandage  were  applied,  and  in 
a  short  time  the  fragments  were  united  firmly  by  bone.  The  nail 
subsequently  fell  off,  and  a  new  one  was  formed." 

The  rule  ought  still  to  be  held  inviolate,  which  surgeons  have  so 
often  repeated  in  reference  to  injuries  inflicted  upon  the  hand  and 
fingers,  namely,  that  we  should  save  always  as  much  as  possible. 

It  is  remarkable,  too,  how  much  nature,  assisted  by  art,  can  do 
toward  the  accomplishment  of  this  purpose.  If  the  bone  of  a  finger 
is  not  only  severed  completely,  but  also  all  of  its  soft  coverings,  save 
only  a  narrow  band  of  integument,  are -torn  asunder,  a  chance  remains 
for  its  restoration.  And  it  is  especially  interesting  to  observe  what 
recuperative  powers  are  possessed  by  the  articular  surfaces  of  these 
smaller  joints,  so  that  although  they  may  be  broken  into,  or  sawn 
through,  or  comminuted,  and  although  small  fragments  be  entirely 
removed,  a  complete  restoration  of  their  functions  is  sometimes  per- 
mitted. I  have  seen  and  reported  some  such  examples.  It  is  true, 
however,  that  such  fortunate  results  are  rare,  and  they  are  rather  to 
be  hoped  for  than  anticipated. 

Since,  in  the  case  of  these  delicate  bones,  the  slightest  deviation 
from  the  natural  form  or  position  determines  in  the  end  an  ugly  de- 
formity, it  becomes  exceedingly  necessary,  especially  with  females, 


334  FEACTURES    OF    THE    PELVIS. 

that  we  should  open  the  dressings  and  examine  the  fingers  carefully 
from  day  to  day,  so  that,  as  the  swelling  subsides,  we  may  discover 
and  correct  any  displacement  which  may  happen  to  exist. 

As  a  splint,  I  have  found  nothing  so  convenient  as  gutta  percha  or 
felt,  moulded  accurately  to  either  the  dorsal  or  palmar  aspect  of  the 
finger ;  and  the  form  of  which  I  have  found  it  generally  necessary  to 
change  slightly  every  third  or  fourth  day,  until  consolidation  is  nearly 
or  quite  completed. 

If  the  fracture  is  near  or  extends  into  a  joint,  the  finger  ought  to 
be  a  little  flexed  so  as  to  place  it  in  the  most  useful  position  in  the 
event  that  anchylosis  should  occur;  and  as  early  as  the  end  of  the 
second  week  the  joint  surfaces  should  be  slightly  moved  upon  each 
other,  in  order  to  the  prevention  of  fibrous  or  bony  adhesions.  Nor  is 
there  much  danger  of  preventing  the  union  of  the  bone  by  moving 
the  joints  at  this  early  day.  Union  occurs  between  these  fragments 
very  speedily,  and  I  have  never  met  with  a  case  of  non-union  of  the 
phalanges,  nor  do  I  remember  to  have  seen  a  case  reported. 

It  is  the  lateral  inclination  of  the  distal  end  of  the  finger  which, 
according  to  my  experience,  it  will  be  found  most  difficult  to  obviate, 
and  which  may,  perhaps,  in  some  cases  be  most  successfully  combated 
by  laying,  the  two  adjoining  sound  fingers  against  the  broken  finger, 
and  then  applying  a  moulded  splint  to  the  palmar  surface  of  the  whole. 
In  other  cases  it  will  be  more  convenient  to  apply  the  splint  only  to 
the  broken  finger. 

Eotation  of  the  lower  fragment  on  its  own  axis  is  especially  to  be 
guarded  against,  as  the  deformity  which  it  occasions  is  more  unseemly, 
and  the  impairment  of  utility  more  decided,  than  that  occasioned  by 
a  lateral  deviation. 

It  may  be  well  also  to  remind  the  surgeon  of  the  convenience  of 
extending  the  splint  beyond  the  end  of  the  last  phalanx,  and  moulding 
it  to  this  extremity,  in  order  that  the  finger  may  be  protected  against 
injuries,  and  that  when,  from  time  to  time,  the  splint  is  removed,  it 
may  be  reapplied  with  accuracy. 

In  all  cases  the  splint  should  be  lined  with  two  or  three  folds  of 
cotton  cloth,  or  with  a  single  piece  of  soft  flannel,  or  patent  lint,  and 
secured  in  place  with  narrow  and  neatly  cut  cotton  rollers.  Bandages 
of  this  width  should  never  be  torn,  but  carefully  cut  with  scissors. 


CHAPTER    XXVII. 

FRACTUEES  OF  THE  PELVIS,  AND  TRAUMATIC  SEPARATIONS 
OF  ITS  SYMPHYSES. 

Development  of  the  Os  Innominatum. — This  bone  is  formed  from 
eight  centres,  three  of  which  are  called  primary,  and  five  secondary. 
The  three  primary  centres  belong  respectively  to  the  ilium,  ischium, 
and  pubes,  and  by  their  extension  form  eventually  the  greater  portion 


PUBES.  335 

of  tlie  innominatum.  They  have  a  common  point  of  union  in  the 
acetabulum  ;  and  the  ischium  unites  with  the  pubes,  also,  by  the  junc- 
tion of  their  rami.  These  conjunctions  occur  usually  between  the 
fifteenth  and  twentieth  years  of  life.  The  secondary  centres  do  not 
begin  to  ossify  until  the  age  of  puberty,  and  may  therefore  properly 
be  considered  as  epiphyses.     One  forms  the  crest  of  the  ilium ;  one 


Development  of  the  os  innominatum.     (From  Gray.) 

its  anterior  inferior  spinous  process;  one  forms  the  symphysis  pubis; 
one  the  tuberosity  of  the  ischium  ;  while  the  fifth  constitutes  the  centre 
of  the  bottom  of  the  acetabulum.  The  epiphyses  become  joined  to 
the  primary  bones,  or  the  bodies  of  the  innorainata,  at  about  the 
twenty-fifth  year. 

§  1.  Pubes. 

Lente,  in  his  reports  from  the  New  York  Hospital,  mentions  the 
case  of  a  young  man,  set.  18,  who  was  crushed  between  a  couple  of 
cars,  in  consequence  of  which  he  died  two  days  after.  The  autopsy 
disclosed  a  separation  at  the  symphysis  pubis,  unaccompanied  with 
any  other  fracture.  The  right  side  was  displaced  backwards  about 
half  an  inch,  so  that  the  fingers  could  be  passed  between  the  bones. 
There  was  also  a  wound  in  the  top  of  the  bladder  large  enough  to 
admit  the  thumb.^     Similar  accidents  have  been  several  times  met  with 

'  Lente,  New  York  Journ.  Med.,  2d  ser.,  vol.  iv.  p.  286. 


336  FRACTURES    OF    THE    PELVIS. 

by  surgeons.  Hall  reports  a  case  in  the  Provincial  Medical  and  Surgi- 
cal Journal,  May  1,  1844,  in  which  the  pubes,  thus  separated,  was 
actually  thrust  into  the  bladder;  but  in  this  example  the  ilium  was 
broken  also.  I  need  scarcely  add  that  this  patient  died  ;^  but  Sir 
Astley  Cooper  has  furnished  us  with  an  example  of  a  simple  fracture 
or  traumatic  separation  at  the  symphysis,  from  which  the  patient  after 
a  long  time  almost  completely  recovered.  The  following  is  Sir  Astley's 
account  of  the  case: — 

"  Case  79.  Eichard  White,  set.  22,  was  admitted  into  Guy's  Hospital 
on  the  30th  of  July,  1832,  having  sustained  a  severe  injury  in  conse- 
quence of  a  large  quantity  of  gravel  having  fallen  upon  his  back  while 
in  the  act  of  stooping.  It  knocked  him  down  ;  and  on  rising,  which 
he  did  with  considerable  difficulty,  he  attempted  to  walk ;  this  pro- 
duced violent  pain  in  the  region  of  the  bladder,  extending  upwards 
in  the  course  of  the  ureters  to  the  kidneys.  Upon  inquiry,  he  stated 
that  the  urine  he  had  voided  since  the  accident  was  bloody  and  passed 
with  difficulty. 

"On  examination,  a  fissure  was  found  at  the  symphysis  pubis,  pro- 
ducing a  separation  of  about  two  fingers'  breadth.  On  pressure  being 
made  upon  any  part  of  the  ilium,  he  complained  of  increased  pain  in 
the  region  of  the  pubes,  and  of  numbness  down  the  left  thigh. 

"A  catheter  was  immediately  passed,  and  the  urine  which  was  drawn 
off  was  clear  and  healthy.  Leeches  were  applied  over  the  pubes,  and 
a  broad  belt  was  firmly  buckled  around  the  pelvis  sufficiently  tight 
to  bring  the  separated  pubes  nearly  in  contact,  and  the  patient  ordered 
to  be  kept  perfectly  quiet  in  the  recumbent  posture,  on  low  diet.  The 
leech-bites  ulcerated,  and  some  slight  degree  of  fever  resulted,  which, 
however,  readily  yielded  to  the  usual  treatment. 

"He  remained  in  the  hospital  for  three  months  without  any  check 
to  the  progress  of  his  cure ;  the  length  of  time  it  required  being 
accounted  for  by  the  difficulty  of  reparation  in  the  amphiarthrodial 
articulation ;  and  when  he  left  there  was  some  slight  separation  of  the 
pubes  remaining ;  nor  were  the  two  lower  extremities,  or  the  anterior 
and  superior  spinous  processes  of  the  ilia,  perfectly  symmetrical, 
although  he  could  walk  very  well."^ 

Malgaigne  has  collected  four  cases  of  simple  separation  at  the  sym- 
physis pubis  occasioned  by  external  violence,  and  in  three  of  the  four 
cases  it  was  occasioned  by  pressing  out  the  thighs  with  great  force  ; 
the  separation  being  directly  due,  therefore,  to  muscular  action. 

Two  of  these  patients  succumbed  to  the  accidents.  The  same  author 
has  brought  together,  also,  seventeen  cases  of  separations  of  this  sym- 
physis occurring  in  childbirth,  of  which  only  seven  survived. 

It  is  much  more  common,  however,  to  find  the  pubes  broken  through 
its  horizontal  or  ascending  ramus ;  and  Clark,  of  the  Massachusetts 
General  Hospital,  has  described  a  case  of  simultaneous  fracture  of  the 
pubes  and  ischium  in  three  places.  The  man,  aet.  29,  had  been  caught 
between  two  heavy  timbers,  and  on  the  following  day,  May  7,  1852, 
he  was  brought  to  the  hospital. 

'  Hall,  Amer.  Journ.  Med.  Sci.,  vol.  xxxiv.  p.  248. 

*  Sir  Astley  Cooper,  Frac.  and  Disloc,  Amer.  ed.,  p.  144. 


PUBES. 


337 


Fig.  109. 


No  crepitus  could  be  detected,  bnt  he  was  unable  to  lie  upon  the 
right  side,  and  the  right  limb  was  nearly  paralyzed.  It  was  evident 
that  the  bladder  or  urethra  had  been  ruptured,  and  on  the  third  day 
Dr.  CUirk  opened  the  bladder  through  the  perineum,  evacuating  a 
large  amount  of  blood  and  urine,  and  affording  to  the  patient  very 
sensible  relief.  On  the  first  of  June,  however,  he  died,  having  sur- 
vived the  accident  twenty-five  days. 

The  autopsy  disclosed  several  fractures,  all  of  which  belonged  to 
the  right  os  innominatum.  First,  a  fracture  of  the  pubes  near  the 
symphysis ;  second,  a  fracture  near  the  junction  of  the  pubes  and  ilium  ; 
third,  a  fracture  through  the  ramus 
of  the  ischium  anterior  to  the  tube- 
rosity.^ 

Sir  Astley  mentions  a  case  (Case 
83)  of  fracture  of  the  "  ramus  of  the 
pubes,"  unaccompanied  with  injury 
to  the  bladder  or  urethra,  which  re- 
sulted in  a  complete  recovery  ;  and 
iu  another  case  (Case  84)  the  patient 
recovered  in  eight  weeks,  and  was 
able  to  walk  nearly  as  well  as  before ; 
but  he  soon  after  died  of  disease  of 
the  chest.  The  os  pubis  was  found, 
at  the  autopsy,  to  have  been  broken 
in  three  places ;  there  was  also  a 
fracture  extending  in  two  directions 
through  the  acetabulum,  with  an 
extensive  comminuted  fracture  of 
the  ilium  accompanied  with  great 
displacement. 

Marat  has  even  found  it  necessary,  after  a  fracture,  to  remove  nearly 
the  whole  of  the  body  of  the  pubes  by  incision,  in  a  girl  of  18  years, 
and  who  not  only  recovered  completely,  but  having  subsequently 
married,  she  gave  birth  to  two  children  in  easy  and  natural  labors.^ 

Cappelletti  relates  that  a  man,  get.  54,  jumped  from  a  carriage,  the 
horses  having  run  away,  and  alighted  with  his  feet  to  the  ground,  but 
with  one  limb  in  the  greatest  possible  degree  of  abduction.  A  surgeon, 
who  saw  him  immediately,  found  an  enormous  swelling  at  the  superior 
part  of  the  thigh,  accompanied  with  very  acute  pain.  When  seen  by 
Cappelletti,  at  Trieste,  six  months  after,  there  still  remained  a  slight 
swelling  near  the  ramus  of  the  ischium  and  pubes,  under  which  a 
careful  examination  detected  a  fragment  of  bone  two  and  a  half  inches 
long  and  of  the  "size  of  the  finger."  The  patient  was  able  to  walk, 
but  not  without  pain  and  limping.  Cappelletti  soon  began  to  suspect 
that  this  fragment  of  bone  consisted  of  a  part  of  the  ramus  of  the 
ischium  and  pubes  detached  by  muscular  contraction.  On  examining 
it  anteriorly  he  found  this  part  of  the  pelvis  defective,  and  the  loose 

•  Clark,  Boston  Med.  and  Surg.  Journ.,  vol.  liii.  p.  185. 
2  Marat,  from  Malgaigne,  op.  cit.,  p.  646. 


Clark's  case  of  fracture  of  the  pelvis. 


338  FRACTURES    OF    THE    PELVIS. 

portion  of  the  bone  had  all  of  the  anatomical  characters  of  the  defective 
part.  He  felt  distinctly  the  circular  projection  indicating  the  point 
where  the  ascending  branch  of  the  ischium  unites  with  the  descending 
branch  of  the  pubes.^ 

Whitaker,  of  Lewistown,  N.  Y,,  saw  the  body  of  the  left  os  pubis 
broken  in  a  female  while  in  the  seventh  month  of  pregnancy.  She 
had  fallen  down  a  pair  of  stairs,  striking  astride  the  edge  of  an  open, 
upright  barrel.  The  fracture  was  oblique,  and  with  but  little  dis- 
placement, yet  she  complained  of  excruciating  pain  in  the  left  pubic 
region  on  the  least  motion.  The  accident  was  followed  by  no  positive 
attempt  at  miscarriage.^ 

The  danger  in  these  accidents  consists  not  so  much  in  the  fracture, 
as  in  the  injury  done  to  the  bladder  and  other  pelvic  viscera.  If  the 
bladder  is  opened  into  the  peritoneal  cavity,  death  is  almost  inevi- 
table; and  even  when  the  bladder  or  urethra  has  suffered  laceration 
lower  down  or  at  any  point  above  the  deep  perineal  fascia,  extensive 
urinary  infiltrations,  followed  by  abscesses  and  gangrene,  generally 
expose  these  patients  to  the  most  imminent  hazards. 

The  practice  pursued  at  Guy's  Hospital  in  the  case  of  separation  at 
the  symphysis  pubis,  commends  itself  both  by  its  simplicity  and  by 
its  success.  Antiphlogistic  remedies  steadily  pursued,  rest  in  the  re- 
cumbent posture,  the  use  of  the  catheter  when  necessary,  and  in  certain 
cases  the  girding  the  pelvis  with  a  firm  belt  or  band,  are  measures 
which  seem  to  meet  all  of  the  important  indications. 

If  the  fracture  is  accompanied  with  displacement  it  will  be  proper 
to  attempt  to  restore  the  fragments,  but  except  in  the  case  of  separa- 
tion at  the  symphysis  very  little  aid  can  be  expected  from  a  band  or 
any  similar  means  in  retaining  them  in  place.  It  will  be  sufficient, 
generally,  in  such  examples  to  place  the  patient  quietly  upon  his  back, 
with  his  thighs  flexed  upon  his  body,  and  to  treat  the  accident  in  all 
other  respects  as  a  case  of  inflammation. 

If  the  urine  has  become  extravasated  underneath  the  pelvic  fascia, 
no  time  ought  to  be  lost  in  opening  freely  through  the  perineum,  and 
in  extending  the  incisions,  if  necessary,  into  the  urethra  and  bladder. 

§  2,  Ischium. 

When  speaking  of  fractures  of  the  pubes  we  have  already  noticed 
some  examples  of  fractures  of  the  ischium  also ;  indeed,  it  is  seldom 
that  one  of  the  bones  of  the  innominatum  is  broken  without  a  coincident 
fracture  of  one  or  both  of  the  others.  The  records  of  surgery  furnish 
several  other  examples,  produced  generally  by  a  fall  upon  the  tubero- 
sities ;  but,  perhaps,  the  most  remarkable  instance  is  that  mentioned 
by  Marat  as  having  occurred  in  a  female  during  labor. 

The  following  summary  of  a  case  of  fracture  of  the  ischium,  reported 
by  Sir  Astley  Cooper,  will  serve  to  illustrate  one  of  the  most  fortunate 

1  Cappelletti,  Banking's  Abstract,  No.  viii.  p.  83  ;  from  Giornale  per  servire  al 
Progressi  della  Patologie  della  Terapeutica,  1847. 

2  Whitaker,  Amer.  Journ.  Med.  Sci.,  July,  1857,  p.  283. 


ISCHIUM.  339 

terminations  of  these  accidents  when  accompanied  with  a  rupture  of 
the  urethra  : — 

A  young  man  who  was  driving  a  cart,  was  thrown  down  and  a 
wheel  passed  over  him.  On  the  following  morning  he  was  found  to 
have  a  fracture  of  the  left  leg  and  a  contusion  of  the  inner  side  of  the 
left  thigh.  There  was  also  great  swelling  and  ecchymosis  of  the 
scrotum,  with  a  slight  appearance  of  injury  over  the  pubes  and  left 
hypochondrium.  No  fracture  of  the  pelvis  was  at  that  time  discovered. 
The  patient  was  suffering  great  pain,  and  was  cold  and  exhausted. 
Bloody  urine  escaped  from  the  bladder.  On  the  eighth  day  an  abscess 
had  pointed  on  the  left  side  of  the  perineum,  which,  being  opened, 
discharged  a  great  quantity  of  pus  having  the  odor  of  urine  ;  extensive 
sloughing  occurred,  and  the  patient  sank  very  low.  On  introducing 
the  finger  into  the  wound,  the  ascending  ramus  of  the  ischium  could 
be  distinctly  felt,  and  the  fracture  traced  in  an  oblique  course,  the 
upper  fragment  being  slightly  displaced  forwards.  When  the  catheter 
was  introduced  into  the  urethra  it  was  found  to  enter  this  wound,  and 
could  be  felt  resting  against  the  naked  bone.  From  this  time  until 
the  twenty-sixth  day,  the  urine  continued  to  escape  freely  through  the 
wound.  In  about  six  weeks  more  the  fistulous  opening  had  entirely 
closed,  and  after  several  months  his  recovery  was  complete.^ 

The  signs  of  this  accident  are  generally  even  more  obscure  than 
those  of  fracture  of  the  pubes,  but  in  a  case  of  doubt  the  bones  ought 
not  only  to  be  carefully  examined  from  without,  but  the  finger  should 
be  introduced  freely  into  the  rectum  and  the  anterior  surface  explored  ; 
or  the  tuber  ischii  may  be  grasped  between  the  thumb  and  finger  and 
moved  laterally  in  order  to  determine  the  existence  of  motion  or  crepi- 
tus. If  the  patient  is  a  female,  this  exploration  can  be  best  made 
through  the  vagina.  By  flexing  and  extending  the  thigh,  also,  crepi- 
tus may  sometimes  be  discovered.  The  examination  will  generally 
be  made  while  the  patient  lies  upon  his  back;  but  if  turning  is  not 
.found  too  painful,  it  will  be  well  to  lay  him  upon  his  face,  that  the 
tuberosities  of  the  ischium  may  be  more  plainly  brought  into  view. 

A  considerable  proportion  of  the  fractures  of  both  the  pubes  and 
the  ischium  are  accompanied  with  lesions  of  the  bladder  or  of  the 
urethra,  either  of  which  circumstances  will  render  the  prognosis  very 
unfavorable;  but  in  simple  fractures  recoveries  may  generally  be 
expected,  yet  only  after  a  tedious  confinement. 

It  is  not  usual,  except  in  cases  which  must  almost  necessarily  prove 
.fatal,  to  find  much  displacement  of  the  fragments ;  nor  is  it  probable 
that  by  any  manoeuvres  the  slight  displacements  which  are  found  to 
exist  can  be  entirely  overcome.  Instances  may  occur,  however,  in 
which  careful  pressure  from  without,  or  the  introduction  of  a  finger 
into  the  rectum  or  vagina,  may  aid  in  the  restoration. 

The  posture  best  suited  to  these  cases  will  be  indicated  usually  by 
the  sensations  of  the  patient  himself.  Ordinarily  he  will  prefer  to  lie 
upon  his  back  with  his  thighs  flexed  and  supported  by  pillows ;  and 
his  hips  slightly  elevated  by  a  firm  cushion  laid  under  the  upper  part 

^  A.  Cooper,  by  Bransby  Cooper,  Amer.  ed.,  p.  1-40. 


340  FRACTUKES    OF    THE    PELVIS. 

of  the  sacrum.  His  knees  ought  also  to  be  gently  bound  together ; 
but  if  the  patient  finds  this  position  painful  or  excessively  irksome, 
as  sometimes  he  will,  he  may  be  permitted  to  occupy  any  position 
which  he  finds  most  comfortable. 

§  3.  Ilium. 

Fractures  of  the  ilium  are  much  more  common  than  fractures  of 
either  the  ischium  or  pubes,  and  they  assume  a  great  variety  of  forms, 
directions,  and  degrees  of  complication. 

In  the  two  following  examples  the  anterior  superior  spinous  process 
alone  was  broken  off: — 

John  Kelly,  £et.  36,  admitted  to  the  Hospital  of  the  Sisters  of  Charity, 
Dec.  28,  1852,  having  just  fallen  and  broken  the  anterior  superior 
spinous  process  of  the  ilium.  The  fragment  was  displaced  downwards 
about  one-quarter  of  an  inch.  Motion  and  crepitus  distinct.  A  slight 
ecchymosis  existed  over  the  point  of  fracture,  and  other  signs  of  con- 
tusion about  the  hip  were  present.  He  was  intoxicated  at  the  time  of 
the  accident,  and  could  not  tell  how  or  where  he  fell. 

He  was  laid  upon  his  back  in  bed,  with  his  thighs  flexed  upon  his 
body;  and  in  this  position  we  attempted  to  reduce  the  fragment  and 
retain  it  in  place  with  a  bandage,  but  finding  this  impossible,  we  left 
him  with  only  instructions  to  remain  quietly  in  bed.  In  about  two 
weeks  the  fragment  was  firmly  fixed  in  its  new  position,  and  he  was 
allowed  to  get  up  and  walk  about,  which  he  was  able  to  do  without 
inconvenience. 

July  13,  1853,  Matthias  Morrison  was  caught  under  a  bank  of  falling 
earth,  and  on  the  following  day  Dr.  Mixer,  his  attending  surgeon, 
requested  me  to  see  the  case  with  him.  He  was  unable  to  stand  upon 
his  feet.  There  was  a  lacerated  wound  and  an  extensive  bruise  on 
his  left  hip  ;  but  the  thigh  was  not  shortened  nor  everted,  and  he  could 
flex  it  slightly  upon  his  body.  Noticing  a  swelling  and  discoloration 
in  the  region  of  the  anterior  superior  spinous  process  of  the  ilium,  I 
pressed  upon  it  and  felt  it  recede  with  a  distinct  crepitus ;  the  frag- 
ment, however,  immediately  resumed  its  place  when  the  pressure  was 
removed.  I  was  able  also,  by  a  careful  manipulation,  to  trace  the  line 
of  fracture,  and  to  determine  that  it  included  a  small  portion  of  the 
anterior  extremity  and  wing  of  the  pelvis. 

We  directed  the  patient  to  remain  quietly  upon  his  bed  with  his 
legs  drawn  up.  He  soon  recovered,  but  I  am  unable  to  say  what  is 
the  present  position  of  the  fragment. 

More  frequently,  however,  the  fracture  involves  a  still  larger  por- 
tion of  the  crest,  as  in  the  following  examples  : — 

Joseph  Joquoy,  aet.  40,  was  caught  by  the  bumpers  between  two 
cars,  Feb.  10,  1854,  breaking  obliquely  the  anterior  superior  portion 
of  the  ilium.  I  saw  him  within  an  hour,  and  found  him  greatly  pros- 
trated; the  fragment  of  the  pelvis  broken  off' was  quite  movable,  and 
crepitus  was  easily  detected.  His  abdomen  was  very  tender  and 
slightly  bloated. 

He  was  laid  upon  his  back  with  his  legs  drawn  up,  and  hot  fomenta- 


ILIUM.  341 

tions  of  hops  and  vinegar  were  directed  to  be  applied  to  his  belly. 
He  also  took  one  grain  of  morphine.  The  broken  ala  did  not  seem 
disposed  to  become  displaced.  With  no  other  treatment,  his  recovery 
was  rapid ;  and  the  bones  seemed  to  have  united  without  displace- 
ment. 

James  Eoche,  set.  41,  fell  March  7,  1854,  from  a  height  of  fourteen 
feet,  breaking  off  the  anterior  superior  portion  of  the  right  ala  of  the 
pelvis.  On  the  following  day,  I  found  him  at  the  hospital  of  the 
Sisters  of  Charity.  The  fragment,  which  was  quite  large,  was  mova- 
ble, and  occasionally  a  crepitus  could  be  detected.  It  was  displaced 
downwards  and  forwards  about  three-quarters  of  an  inch. 

He  was  laid  upon  his  back,  with  his  thighs  and  legs  moderately 
flexed.  At  the  end  of  two  weeks  he  found  himself  able  to  walk  with- 
out much  difficulty,  and  he  immediately  left  the  hospital.  At  this 
time  the  fragment  was  displaced  in  the  same  manner  and  direction  as 
at  first,  but  I  cannot  say  whether  it  had  united  or  not. 

I  have  three  other  similar  cases  upon  my  records ;  but  in  the  last 
example,  the  sixth,  which  has  been  especially  recorded,  the  fracture 
was  caused  by  muscular  action.  William  Alexander,  aet.  70,  on  the 
fifth  of  September,  1869,  after  riding  in  a  railroad  car  about  half  an 
hour,  arose  to  leave  his  seat,  when  he  felt  "  something  wrong"  in  his 
right  groin,  and  found  himself  unable  to  walk  without  great  pain.  He 
was  admitted  to  Bellevue  Hospital  on  the  same  day,  and  I  found  a 
fracture  involving  about  three  inches  of  the  ilium,  including  the  ante- 
rior superior  spinous  process.  It  was  inclined  to  fall  outward,  but 
was  easily  replaced  with  a  distinct  crepitus. 

I  have  once  seen  a  fracture  of  the  posterior  superior  spinous  process, 
and  I  do  not  know  of  any  other  example. 

Miss  B.,  aet.  19,  was  thrown  from  her  horse  backwards,  striking  with 
her  back  upon  the  ground.  She  was  first  attended  by  Dr.  Coan,  of 
Ovid,  N.  Y. ;  and  she  did  not  come  under  my  care  until  two  weeks 
after  the  accident. 

I  found  a  small  fragment  broken  from  the  posterior  superior  spinous 
process  of  the  ilium,  and  displaced  backwards  in  the  direction  of  the 
spine  about  half  an  inch.  It  was  movable,  and  by  pressure  it  could 
be  partially  restored  to  place,  but  it  would  immediately  return  to  its 
abnormal  position  when  the  pressure  was  removed.  The  injured  hip 
was  painful,  and  occasionally  it  felt  numb.  She  had  previously  suf- 
fered from  spinal  irritation. 

I  laid  a  compress  behind  the  fragment,  and  secured  it  in  place  with 
a  roller,  enjoining  perfect  rest.  She  recovered  from  her  lameness  in 
a  few  weeks,  but  I  believe  the  fragment  remains  displaced. 

Extensive  comminuted  fractures  of  the  ilium  are  generally  accom- 
panied with  so  much  injury  of  the  pelvic  viscera  as  to  prove  rapidly 
fatal ;  but  the  following  example  will  show  that  this  rule  admits  of 
exceptions. 

June  5,  1854,  Bernard  Duffie,  set.  32,  was  crushed  under  a  very 
heavy  stone  which  fell  upon  his  back.  I  found  the  left  ala  of  the 
pelvis  broken  into  several  fragments,  between  the  different  portions  of 
which  motion  and  crepitus  were  distinct.     The  fractures  were  near  the 


842  FRACTURES    OF    THE    PELVIS. 

superior  part  of  the  bone,  commencing  about  two  inches  back  of  the 
anterior  superior  spinous  process,  and  extending  backwards  irregu- 
larly. There  was  a  narrow  wound  communicating  with  the  fracture, 
from  which  I  removed  a  loose  fragment  of  bone.  The  right  leg  was 
also  broken. 

Four  months  after,  he  was  still  confined  to  his  bed,  and  a  fistulous 
opening  continued  opposite  the  point  of  fracture ;  there  existed  also  a 
large  and  irregular  mass  of  osslfic  matter  or  callus  around  the  frag- 
ments.    He  soon  after  left  the  hospital. 

Dr.  Sargent,  of  the  Massachusetts  General  Hospital,  has  reported  a 
case  in  which  a  man  received  a  compound  fracture  of  the  left  ilium, 
and  several  small  fragments  were  removed.  He  was  discharged  at 
the  end  of  three  months  with  a  fistulous  opening  still  remaining,  but 
in  other  respects  he  was  quite  well.^  Dr.  Cheever,  of  the  same  hos- 
pital, reports  a  case  of  fracture  of  the  ilium,  with  fracture  of  the 
ascending  ramus  of  the  pubes,  resulting  in  complete  recovery ;  but 
the  leg  became  shortened  and  the  toes  inverted.  Dr.  Cheever  believes 
that  the  lines  of  fracture  met  in  the  acetabulum.^ 

The  following  case  illustrates  the  more  fatal  injuries  of  this  cha- 
racter : — 

John  O'Keaf  was  crushed  under  a  heavy  stone,  Oct.  23, 1851,  break- 
ing and  comminuting  the  alse  of  the  pelvis  on  both  sides,  and  wound- 
ing also  the  iliac  vein.  He  was  taken  to  the  hospital  of  the  Sisters  of 
Charity,  and  died  in  a  few  hours,  partly  from  the  shock  to  his  system 
and  partly  from  the  hemorrhage. 

Lente,  of  the  New  York  Hospital,  has  reported  a  case  of  dislocation 
of  the  hip,  which  was  accompanied  with  a  fracture  also  of  the  ala  of 
the  pelvis  upon  the  same  side.  The  dislocation  was  reduced  on  the 
third  day,  and  the  patient  soon  after  died.  The  autopsy  disclosed 
what  had  not  been  suspected  during  life,  namely,  that  the  left  ilium 
was  broken  horizontally  about  through  its  middle,  and  vertically 
through  the  crest ;  and  also  that  there  was  a  fracture  extending  through 
the  sacro-iliac  synchondrosis,  accompanied  with  considerable  commi- 
nution of  the  articular  surfaces.  It  was  also  found  that  a  portion  of 
the  small  intestine  was  ruptured,  and  probably  by  one  of  the  sharp 
fragments  of  the  broken  pelvis.' 

It  is  seldom,  I  think,  that  the  fragments  become  much  displaced; 
such,  at  least,  has  been  my  experience  ;  and  I  have  noticed  in  Dr. 
Neill's  cabinet  three  specimens  of  fracture  of  the  crest  of  the  ilium,  all 
of  which  had  united  without  any  appreciable  displacement.  Dr.  Neill 
also  called  my  attention  to  the  fact  that  in  two  of  these  specimens  the 
ensheathing  callus  was  confined  to  the  outer  surface  of  the  bone ;  an 
observation  which  this  gentleman  assures  me  he  has  had  frequent 
occasion  to  make  before  where  the  fracture  belonged  to  a  flat  bone. 

If  any  displacement  exists,  the  upper  or  loose  fragpient  is  generally 
carried  slightly  inwards  ;  occasionally,  however,  it  is  found  displaced 
upwards,  outwards,  or  downwards. 

1  Sargent,  Boston  Med.  and  Surg.  Journ.,  vol.  liii.  p.  121. 

2  Cheever,  Bost.  Med.  and  Surg.  Journ.,  May  3,  18G6. 

3  Lente,  New  York  Journ.  of  Med.,  Jan.  1851,  p.  29. 


ACETABULUM,  343 

Treatment. — In  a  large  majority  of  cases  the  fragments,  if  displaced, 
cannot  be  completely  replaced.  Occasionally,  however,  as  where  the 
anterior  superior  spinous  process  is  broken  oft'  with  only  a  small  por- 
tion of  the  crest,  the  fragment  maybe  seized  with  the  fingers  and  car- 
ried outwards  or  upwards,  or  in  whatever  direction  may  be  necessary ; 
but  to  retain  it  in  this  position  is  generally  quite  impossible.  The 
bandage  or  broad  belt  which  we  have  recommended  in  certain  frac- 
tures of  the  pubes  would  be  in  these  cases  not  only  useless,  but  abso- 
lutely mischievous,  since  its  effect  must  be  to  press  inwards  the  frag- 
ments, and  thus  to  create  a  displacement  which  might  not  otherwise 
exist. 

The  surgeon  ought  to  determine  by  a  careful  examination  the  extent 
and  direction  of  the  fracture,  and,  having  done  what  was  in  his  power 
to  replace  the  fragments,  he  should  lay  his  patient  upon  his  back  with 
the  thighs  drawn  up  and  supported.  This  is  the  position  which  will 
generally  be  found  most  comfortable  ;  but,  as  in  other  fractures  of  the 
pelvis,  it  may  be  well  always  to  try  the  effect  of  other  positions,  and 
especially  to  determine  their  influence  upon  the  fragments,  and  finally 
to  adopt  that  precise  posture  which  accomplishes  the  indications  best. 

If  the  fracture  is  compound,  and  the  fragments  have  penetrated  the 
belly,  the  wound  should  be  enlarged,  and,  as  far  as  possible,  every  piece 
of  bone  should  be  removed ;  but  if  the  fragments  cannot  be  found, 
the  external  opening  should  be  allowed  to  remain  so  as  to  favor  their 
escape  when  suppuration  shall  have  taken  place, 

§  4.  Acetabulum. 

Although,  strictly  speaking,  fractures  of  the  acetabulum  belong 
always  to  one  or  all  of  those  bones  of  the  pelvis  whose  lesions  have 
already  been  described,  yet  the  peculiar  relations  of  this  cavity  to  the 
femur  render  it  necessary  that  they  should  be  considered  as  a  separate 
class  of  accidents. 

Fractures  of  the  acetabulum  divide  themselves  naturally  into  two 
varieties. 

First.  Fractures  of  the  base  of  the  cavity,  with  or  without  displace- 
ment. 

Second.  Fractures  of  the  rim,  with  or  without  displacement. 

In  fractures  of  the  base  of  the  cavity,  not  accompanied  with  displace- 
ment, nothing  but  crepitus  can  be  present  as  a  sign  of  the  accident ; 
and  this  will  scarcely  be  sufficient,  in  itself,  to  enable  the  surgeon  to 
distinguish  it  from  a  fracture  of  the  neck  of  the  femur  within  the 
capsule  without  displacement. 

It  is  probable,  therefore,  that  its  existence  will  only  be  determined 
by  dissection.  Nor  is  it  of  much  importance  that  the  diagnosis  should 
be  made  out;  since  in  either  case  neither  splints  nor  any  other  sur- 
gical appliances  could  be  of  service.  An  injury  so  severe  as  to  frac- 
ture the  acetabulum  will  necessarily  so  much  bruise  the  body,  and 
concuss  the  viscera  of  the  pelvis,  as  to  compel  the  patient  to  remain 
quiet  for  a  number  of  days,  and  this  is  all  that  would  be  thought 
necessary  if  the  nature  of  the  accident  was  exactly  determined. 


344  FRACTUEES    OF    THE    PELVIS. 

Dr.  Neill's  cabinet  contains  a  specimen  of  tins  kind,  in  which  the 
fracture,  commencing  near  the  centre,  extends  in  three  directions 
across  the  cotyloid  margins ;  and  in  which  perfect  bony  union  has 
occurred  without  displacement. 

M.  Bouvier  related  to  the  Academy  the  case  of  a  man,  set.  71,  who, 
in  consequence  of  a  fall  from  his  bed,  remained  for  three  weeks  unable 
to  walk,  and  never  was  able  afterwards  to  walk  without  crutches.  No 
fracture  could  be  discovered  during  life,  but  after  his  death,  which 
occurred  some  months  subsequent  to  the  accident,  a  fracture  was 
found  extending  from  the  ilio-pectineal  eminence  to  the  spine  of  the 
ischium,  and  traversing  the  centre  of  the  acetabulum.  The  fragments 
were  not  displaced,  but  remained  slightly  movable.^ 

The  following  case  was  reported  by  Mr.  Earle,  to  the  London 
Medico-Chirurgical  Society,  and  will  be  found  in  the  nineteenth 
volume  of  its  Transactions.  It  is  also  referred  to  by  Sir  Astley,  in 
his  Treatise  on  Fractures  and  Dislocations. 

In  the  month  of  October,  1829,  a  man,  ae.t.  40,  was  admitted  into 
St.  Bartholomew's  Hospital,  with  a  severe  injury  caused  by  having 
fallen  from  a  height  of  thirty-one  feet  and  striking  upon  the  left  side. 
The  left  leg  was  powerless,  and  shortened.  The  foot  was  everted. 
Any  attempt  to  rotate  the  limb  caused  great  pain,  and  was  accom- 
panied with  a  sensible  crepitus.  The  left  trochanter  was  very  much 
depressed,  and  when  it  was  pressed  upon  the  patient  complained  of 
deep-seated  pain  in  the  hip-joint. 

He  recovered  in  eight  weeks,  and  was  able  to  walk  nearly  as  well 
as  before ;  but  he  soon  after  died  of  disease  in  the  chest. 

On  dissection,  a  fracture  was  found  extending  in  two  directions 
through  the  acetabulum  ;  there  was  an  extensive  comminuted  fracture 
of  the  ilium,  with  great  displacement,  and  the  os  pubis  was  broken  in 
three  places. 

The  repair  was  very  complete,  and  Mr.  Earle  remarked  how  nature 
had  guarded  against  any  considerable  deposit  of  new  bone  within  the 
articulation,  which  might  have  interfered  with  the  functions  of  the 
joint,  while  there  was  an  abundant  deposit  of  callus  around  the  other 
parts  of  the  fractured  bone. 

Mr.  Travers  has  reported  two  similar  cases,  and  in  the  paper  accom- 
panying the  report  he  maintains  that  very  acute  pain  caused  by  press- 
ing upon  the  projecting  spine  of  the  os  pubis,  and  the  inability  of  the 
patient  to  maintain  the  erect  posture,  may  be  regarded  as  signs 
diagnostic  of  the  accident.^  It  is  doubtful,  however,  whether  these 
phenomena,  so  common  to  many  other  accidents,  could  be  relied  upon 
as  evidence  of  this  peculiar  lesion. 

Fractures  of  the  base  of  the  acetabulum,  with  displacement  of  the 
femur  into  the  pelvic  cavity,  constitute  a  much  more  formidable,  and 
unfortunately  a  more  common  form  of  accident. 

Like  the  preceding  variety  of  acetabular  fractures,  they  are  pro- 

'  Bouvier,  Amer.  Journ.  Med.  Sci.,  vol.  xxiii.  p.  486 ;  from  Bullet,  de  I'Acad. 
Roy.  de  Med.,  August  15,  1838. 
2  Travers,  Holmes'  System  of  Surgery,  vol.  ii.  p.  478. 


BASE    OF    THE    ACETABULUM.  .        345 

duced  generally  by  falls  upon  the  trochanter  major,  "but  the  force  of 
the  concussion  has  been  greater. 

Even  here,  it  is  not  often  that  the  diagnosis  has  been  clearly  made 
out  during  life;  and  indeed,  generally,  the  true  character  of  the  acci- 
dent has  not  even  been  suspected,  the  surgeons  believing  that  they 
had  to  do  with  a  fracture  of  the  neck  of  the  femur,  or  with  a  disloca- 
tion. In  two  examples  (Cases  71  and  72)  mentioned  by  Sir  Astley 
Cooper  as  having  been  presented  at  St.  Thomas's  Hospital,  the  thigh 
was  thought  to  be  dislocated  backwards. 

In  the  following  example  reported  by  Lendrick,  of  Dublin,  the 
patient  was  supposed  to  have  a  fracture  of  the  neck  of  the  femur : — 

An  old  man,  well  known  as  the  "Wandering  Piper,"  was  admitted 
into  the  Mercer  Hospital  in  January,  1839,  suffering  under  phthisis 
pulmonalis  and  acute  inflammation  of  the  hip-joint.  Some  years 
before,  he  had  received  a  severe  injury  by  the  upsetting  of  a  coach, 
and  was  under  treatment  several  months  for  what  was  supposed  to  be 
a  fracture  of  the  neck  of  the  femur.  Since  that  time  he  had  been 
lame,  but  still  able  to  take  a  great  deal  of  exercise  on  foot  both  in 
Great  Britain  and  in  America.  The  acute  disease  of  the  joint  com- 
menced about  two  months  before  his  admission,  and  he  was  at  first 
under  the  care  of  Sir  Philip  Crampton,  who  remarked  that  the, thigh 
was  only  shortened  about  half  an  inch,  and  expressed  his  surprise  at 
this  fact. 

This  man  died  on  the  17th  of  February,  and  the  dissection  showed 
that  there  had  been  no  fracture  of  the  femur,  but  its  head  and  neck 
were  affected  with  ''  morbus  coxas  senilis.''  The  head  was  also  thrust 
through  a  rent  in  the  acetabulum  into  the  cavity  of  the  pelvis;  but 
the  head  had  again  been  covered  by  a  bony  case,  complete,  except  in 
a  small  portion  about  the  size  of  a  shilling  piece,  and  at  this  point  the 
covering  was  ligamentous. 

The  OS  pubis  had  also  been  broken  at  the  same  time,  and  it  had 
united  so  much  overlapped  that  the  space  between  the  inferior  ante- 
rior spinous  process  and  the  symphysis  pubis  was  shortened  nearly 
an  inch.  A  portion  of  intestine  was  found  protruding  through  an 
opening  in  the  pelvis  and  adherent  to  the  bone,  in  which  situation  it 
seemed  to  have  been  caught  by  the  broken  fragments  and  retained.^ 

Morel-Lavallee,  in  his  thesis  upon  complicated  luxations,  mentions 
a  case  which  had  come  under  his  observation,  and  which  had  been 
treated  as  a  fracture  of  the  neck  of  the  femur.  The  patient  survived 
the  accident  many  years;  during  a  part  of  which  time  he  suffered 
such  pain  in  the  hip-joint  as  to  induce  a  belief  that  it  was  itself 
diseased.  At  his  death  he  was  found  to  have  had  a  multiple  fracture 
of  the  bones  of  the  pelvis,  and  the  head  of  the  femur  had  penetrated 
more  than  an  inch  into  the  cavity  of  the  pelvis,  pressing  upon  the 
obturator  nerve  to  such  a  degree  as  to  have,  no  doubt,  caused  the 
severe  pain  from  which  he  had  suffered,  and  which  had  been  ascribed 
to  coxalgia.^ 

'  Lendrick,  Amer.  Journ.  Med.  Sci.,  vol.  xxiv.  p.  481;   August,  1839;   from 
London  Med.  Gazette,  March,  1839. 
2  Morel-Lavallee,  from  Malgaigne,  op.  cit.,  vol.  ii.  p.  881. 
23 


846  FRACTURES    OF    THE    PELVIS. 

In  the  two  cases  mentioned  by  Sir  Astley  as  having  been  received 
into  St.  Thomas's  Hospital,  the  toes  were  turned  in.  In  the  example 
mentioned  by  the  same  author  as  having  been  presented  at  St.  Bar- 
tholomew's Hospital,  the  toes  were  everted ;  the  two  persons  seen  by 
Lendrick  and  Morel-Lavallee  were  supposed  before  death  to  have  had 
a  fracture  of  the  neck;  it  is  probable,  therefore,  that  in  both  of  these 
cases  the  toes  were  also  everted.  While  Moore  has  dissected  a  subject 
whose  pelvis  was  broken  into  many  fragments — the  left  os  innomina- 
tum  was  divided  into  three  portions,  corresponding  to  the  three  bones 
of  which  it  was  composed  in  infancy;  the  head  of  the  femur  had  com- 
pletely penetrated  the  basin;  the  limb  was  shortened  two  inches,  and 
in  a  position  of  slight  flexion  and  adduction,  but  neither  rotated  out- 
wards nor  inwards.' 

There  seems,  therefore,  to  be  no  certain  rule  in  relation  to  the  posi- 
tion of  the  limb;  but  it  is  found  to  take  the  one  position  or  the  other, 
probably  according  to  the  direction  of  the  force  which  has  inflicted  the 
injury,  and  perhaps  in  obedience  to  circumstances  not  always  easily 
explained. 

The  shortening  has  been  observed  to  vary  from  half  an  inch  to  two 
inches  or  more;  the  trochanter  is  also  usually  driven  in  toward  the 
pelvis.  Pressure  upon  the  trochanter  occasions  a  deep-seated  pain. 
If  the'  limb  is  drawn  down  to  the  same  length  with  the  other,  it  im- 
mediately resumes  its  position  when  the  extension  is  discontinued. 
Crepitus  is  more  uniformly  present  than  in  fractures  of  the  neck  of 
the  femur,  and  it  is  especially  felt  while  the  limb  is  being  extended  or 
while  it  is  again  shortening,  and  not  so  much  in  flexion  or  rotation. 

If,  in  addition  to  all  of  these  phenomena,  we  learn  that  the  accident 
has  occurred  from  a  severe  blow,  or  a  fall  from  a  great  height  upon 
the  trochanter ;  and  that  the  viscera  of  the  pelvis,  and  especially  the 
bladder,  seem  to  have  suffered  considerable  injury;  or  if  we  detect  at 
the  same  time  a  fracture  of  some  other  portion  of  the  pelvis — we  may 
reasonably  conclude  that  the  head  of  the  femur  has  penetrated  the 
acetabulum.  Yet  it  must  be  confessed  that  no  one  of  these  symptoms 
is  positively  distinctive  of  this  accident,  and  that  they  are  seldom  found 
sufficiently  grouped  to  render  the  diagnosis  certain. 

The  old  "Piper"  mentioned  by  Lendrick,  and  the  man  dissected  by 
Morel-Lavallee,  lived  many  years,  and  managed  to  walk  about,  but 
not  without  considerable  pain;  the  other  three,  to  whom  I  have 
alluded,  died  soon  after  the  injuries  were  received. 

Some  have  thought  of  treating  these  cases  by  extension  and  counter- 
extension  ;  the  latter  being  accomplished  through  the  aid  of  a  perineal 
band  ;  but  it  is  not  probable  that  after  an  injury  of  this  character,  any 
patient  will  be  able  to  endure  the  requisite  pressure  about  the  peri- 
neum or  groins.  It  will  be  better  to  lay  the  patient  upon  Daniel's 
invalid  bed,  or  some  bed  similarly  constructed,  so  that  it  may  be  con- 
verted into  a  double-inclined  plane;  allowing  the  knees  to  be  sus- 
pended over  the  angle  thus  formed,  in  order  that  the  weight  of  the 
body  may  have  some  effect  to  draw  away  the  pelvis  from  the  femur. 

'  Moore,  Med.-Chir.  Trans.,  vol.  xxxiv.  p.  107,  1851. 


EIM    OF    THE    ACETABULUM.  347 

Or  we  may  adopt  extension  without  the  perineal  band,  as  will  be 
described  hereafter  when  treating  of  fractures  of  the  femur. 

Fractures  of  the  rim  of  the  acetabulum  have  frequently  been  dis- 
covered in  dissections;  and  the  records  of  surgery  abound  with  cases 
of  unreduced  dislocations  of  the  femur,  in  which  the  failure  to  reduce 
or  to  retain  the  bone  in  place  has  been  ascribed,  not  always  with  suffi- 
cient reason  perhaps,  to  this  fracture. 

Dr.  McTyer,  of  the  Glasgow  Royal  Infirmary,  published  in  the  Glas- 
gow Medical  Journal  for  February,  1830,  four  cases  of  this  fracture. 

The  first  was  that  of  a  man,  set.  27,  on  whose  back  a  number  of 
bricks  had  fallen  while  he  had  his  right  knee  placed  on  the  bank  of  a 
trench.  His  right  leg  was  found  shortened  about  one  inch  and  a  half, 
bent,  and  the  toes  turned  a  little  outwards.  The  limb  could  be  moved 
without  much  difficulty,  but  every  motion  gave  him  pain ;  motion 
was  also  attended  with  crepitus.  On  making  extension,  the  limb  was 
easily  brought  to  the  same  length  with  the  other,  but  it  became 
shortened  again  immediately  when  the  extension  was  discontinued. 

The  symptoms,  differing  but  little,  if  at  all,  from  those  which  are 
usually  present  in  a  case  of  fracture  of  the  neck  of  the  femur,  led  to 
the  supposition  that  this  was  actually  the  nature  of  the  accident. 
Subsequently,  the  toes  became  slightly  turned  in,  but  this  circum- 
stance was  not  regarded  as  sufficiently  distinctive  to  warrant  a  change 
in  the  diagnosis. 

Having  succumbed  to  the  injuries  after  a  few  days,  the  autopsy 
revealed  a  fracture  extending  through  the  bottom  of  the  right  aceta- 
bulum, and  about  one  inch  and  a  half  of  the  rim  at  its  upper  and 
posterior  margin  completely  detached,  except  as  it  was  held  in  place 
by  a  portion  of  the  capsular  ligament.  The  head  of  the  bone  could 
be  easily  pushed  upwards  and  backwards  upon  the  dorsum,  the  frag- 
ment of  the  acetabular  margin  being  moved  aside,  and  swinging  upon 
its  fibrous  attachment  as  upon  a  hinge,  but  resuming  its  place  again 
perfectly  when  the  head  of  the  femur  was  restored  to  the  socket.  The 
femur  was  not  broken. 

In  the  second  case  the  limb  was  found  shortened,  the  knee  slightly 
bent,  and  turned  a  little  forwards  and  inwards,  and  the  toes  pointing 
to  the  tarsus  of  the  other  foot.  It  was  thought  to  be  a  fracture  also- 
of  the  neck  of  the  femur,  but  the  autopsy  disclosed  only  a  fracture  of 
the  upper  margin  of  the  rim  of  the  acetabulum. 

In  the  third  case,  seen  only  after  death,  the  limb  was  not  shortened 
much,  but  the  toes  were  stretched  downwards,  and  turned  slightly 
inwards.  It  was  supposed  at  first  to  be  a  simple  dislocation,  but  on, 
dissection  the  posterior  and  inferior  margin  of  the  acetabulum  was 
found  to  be  broken  and  displaced  towards  the  coccyx,  while  the  head 
of  the  femur  rested  upon  the  pyriformis  muscle,  over  the  ischiatic 
notch. 

The  fourth  example  was  found  in  the  dissecting-room,  and  the  his- 
tory of  the  case  is  not  known.  A  fragment  of  the  superior  and  pos- 
terior margin  of  the  acetabulum  had  been  broken  ofi"  and  had  reunited 
slightly  displaced.^ 

'  McTyer,  Amer.  Journ.  Med.  Sci.,  vol.  viii.  p.  517,  Aug.  1831. 


848  FEACTURES    OF    THE    PELVIS. 

Several  other  similar  examples  have  been  established  by  dissection/ 
and  we  are  able,  therefore,  to  determine  pretty  accurately  what  are 
the  usual  phenomena  and  terminations  of  this  accident,  though  we  are 
far  from  having  arrived  at  a  satisfactory  means  of  diagnosis ;  indeed,, 
the  accident  has  seldom  been  recognized  before  death.  Its  causes  are 
generally  the  same  with  those  which  produce  dislocations  of  the  hip, 
but  in  most  instances  the  violence  has  been  greater  than  in  the  case 
of  dislocations. 

The  symptoms  are,  first,  such  as  indicate  a  dislocation,  to  which 
must  be  added  crepitus  and  a  difficulty,  if  not  impossibility,  of  retain- 
ing the  head  of  the  femur  in  its  place  when  it  is  reduced.  The  crepitus 
is  sometimes  discovered  the  moment  we  begin  to  move  the  limb,  and 
this  will  aid  us  to  distinguish  it  from  a  fracture  of  the  neck  of  the 
femur  accompanied  with  much  displacement,  since,  in  the  latter  case, 
crepitus  is  not  felt  usually  until  the  extension  is  complete,  and  the 
fragments  are  again  brought  into  apposition. 

The  majority  of  these  accidents,  either  from  a  failure  to  recognize 
them,  or  from  the  impossibility  of  maintaining  the  head  of  the  femur 
in  place  when  once  it  has  been  reduced,  have  resulted  in  a  permanent 
dislocation  of  the  hip  and  a  serious  maiming.  The  following  case 
was  recognized  and  reduced,  but  it  was  found  impossible  to  maintain 
the  reduction. 

February  3,  1847,  a  strong  German  laborer  was  crushed  under  a 
mass  of  iron  weighing  several  tons.  Drs.  Sprague  and  Loomis,  of 
Bui^alo,  were  called,  and  found  the  left  thigh  dislocated  upwards  and 
backwards,  and  by  the  aid  of  six  men  they  succeeded  in  reducing  it, 
the  reduction  being  attended,  as  the  gentlemen  have  informed  me,  with 
a  slight  sensation  of  crepitus.  The  legs  were  then  laid  beside  each 
other,  and  the  knees  tied  together,  the  patient  lying  on  his  back  ;  and 
now  the  two  limbs  appeared  to  be  of  the  same  length.  On  the  second 
and  third  days  the  injured  limb  was  examined  by  the  same  gentlemen, 
and  there  was  no  displacement.  On  the  fourth  day  I  was  invited  to 
meet  these  gentlemen,  the  patient  having  had  muscular  spasms  during 
the  previous  night,  and  the  thigh  being  reluxated.  I  found  the  limb 
shortened  one  inch  and  a  half,  adducted,  and  the  toes  turned  in.  We 
immediately  applied  the  pulleys,  and  soon  drew  the  trochanter  down 
to  a  point  apparently  opposite  the  acetabulum,  and  a  careful  measure- 
ment showed  that  the  two  limbs  were  of  the  same  length.  The  pulleys 
being  removed,  the  leg  did  not  draw  up  again,  nor  did  the  foot  turn 
in,  yet  we  had  felt  no  sensation  to  indicate  that  the  bone  had  slipped 
into  its  socket,  nor  had  we  felt  crepitus.  The  legs  and  thighs  were 
now  laid  over  a  double-inclined  plane,  and  well  secured.  He  remained 
in  this  condition  three  days  more,  during  which  time  Dr.  Sprague  saw 
him  each  day,  and  found  nothing  disarranged.  On  the  night  of  the 
seventh  day  the  spasms  returned,  and  in  the  morning  the  thigh  was 
displaced.     The  next  day  we  again  applied  the    pulleys,  but  soon 

'  Maisonneuve,  Chirurg.  Clin.,  1863,  p.  168.  Sir  Astley  Cooper  on  Disloc.  and 
Frac,  1823,  second  London  edition,  p.  15.  M.  Beraud,  Bulletin  do  la  Soc.  de  Cliir., 
1862,  torn.  iiL  p.  185.     Ibid.,  p.  226.    Bigelow  on  Hip-Joint,  1869,  p.  139  et  seq. 


SACKUM.  349 

found  that  the  bone  would  not  remain  in  place  one  minute  after  the 
pulleys  were  removed. 

At  this  time,  while  moderate  extension  was  being  made  at  the  foot 
by  rotating  the  foot  inwards,  we  could  distinctly  feel  a  slight  crepitus. 
A  straight  splint  was  applied,  and  as  much  extension  made  as  he  could 
conveniently  bear,  and  in  this  condition  the  limb  was  kept  several 
weeks.  Seven  years  after,  I  found  the  thigh  still  displaced  upon  the 
dorsum  ilii.  He  limped  badly,  but  he  could  walk  fast,  and  perform 
as  much  labor  as  before  the  accident. 

In  one  case  mentioned  by  Mr.  Keate,  the  bone  had  become  dislo- 
cated downwards,  and  could  be  felt  lying  against  the  tuber  ischii,  and 
the  presence  of  a  "distinct  grating  as  of  ruptured  cartilage"  led  him 
to  conclude  that  the  cartilaginous  labrum  of  the  socket  was  broken 
off;  but  as  the  fracture  was  in  the  lower  margin  of  the  socket,  no 
difficulty  was  experienced  in  retaining  the  bone  in  position.^ 

If  the  diagnosis  is  satisfactorily  made  out,  and  upon  complete  re- 
duction the  femur  will  not  remain  in  place,  the  treatment  ought  to  be 
the  same  as  for  a  fracture  of  the  thigh,  except  that  no  lateral  splints 
or  bandages  to  the  thigh  will  be  necessary.  The  limb  ought  to  be 
kept  drawn  out  to  its  proper  length,  as  far  as  this  shall  be  found  to  be 
practicable,  by  extending  and  counter-extending  apparatus.  A  band 
around  the  pelvis,  so  adjusted  as  to  press  the  head  of  the  bone  into  its 
socket,  may  also  be  of  service  in  preventing  the  tendency  to  displace- 
ment; and  in  case  the  bone  manifests  little  or  none  of  this  tendency, 
the  hip  bandage  will  probably  alone  be  sufficient,  yet  even  here  no 
harm  could  come  of  applying  the  long  straight  splint  and  the  extend- 
ing apparatus,  secured  moderately  tight,  simply  as  a  measure  of  pre- 
caution. Dr.  Bigelow  recommends  angular  extension,  effected  by 
means  of  an  angular  splint,  such  for  example  as  Nathan  R.  Smith's,  or 
Hodgen's,  suspended  from  the  ceiling,  or  from  some  other  point  above 
the  patient;  "'or,"  he  adds,  "  if  any  manoeuvre  has  reduced  the  bone, 
the  limb  should  be  retained,  if  possible,  in  the  attitude  which  completed 
the  manoeuvre." 

§  5.  Sacrum. 

Simple  fractures  of  the  sacrum,  known  to  be  exceedingly  rare,^  are 
occasioned  either  by  such  injuries  as  break  at  the  same  time  the  other 
bones  of  the  pelvis,  or  by  blows  or  falls  received  directly  upon  the 
sacrum.  It  may  be  broken  at  any  point,  and  in  any  direction,  when 
the  fracture  is  produced  by  the  first  of  this  class  of  causes  ;  but  if  the 
fracture  is  the  result  of  a  fall  upon  the  sacrum,  it  will  generally  be 
transverse,  and  below  the  sacro-iliac  symphysis.  The  displacement  in 
this  latter  class  of  cases  is  almost  invariably  the  same,  the  coccygeal 
extremity  being  simply  carried  forwards,  yet  this  is  seldom  sufficient 
to  interfere  in  any  degree  with  the  functions  of  the  rectum  and  anus; 
but  in  one  case  seen  by  Bermond  it  nearly  closed  the  rectum.     Some- 

'  Keate,  Amer.  Journ.  of  Med.  Sci.,  vol.  xvi.  p.  225. 

2  Malgaigne  has  referred  to  eiglit  cases  ;  and  I  have  not  been  able  to  find  a  record 
of  any  others. 


350  FRACTURES    OF    THE    PELVIS. 

times,  also,  there  is  a  slight  lateral  deviation.  There  is  also  in  the 
Dupuytren  museum,  at  Paris,  a  specimen  in  which  the  whole  of  the 
lower  fragment  is  displaced  a  little  forwards. 

The  signs  of  this  fracture  are  pain  at  the  seat  of  injury,  aggravated 
greatly  in  the  attempts  to  flex  or  elevate  the  body,  and  especially  in 
the  efforts  at  defecation ;  swelling  and  discoloration  of  the  soft  parts 
covering  the  sacrum  ;  displacement  of  the  coccyx  forwards  ;  an  angu- 
lar projection  at  the  point  of  fracture,  with  a  corresponding  retiring 
angle  upon  the  opposite  side;  mobility. 

Experience  has  shown  that  where  the  fracture  of  the  sacrum  is 
accompanied  with  other  fractures  of  the  pelvis,  the  patients  seldom 
recover;  and  only  because  so  extensive  an  injury  implies  usually 
great  force  in  the  cause  which  produced  the  fractures,  and,  of  neces- 
sity, greater  lesions  among  the  pelvic  viscera.  Simple  fractures,  from 
falls  upon  the  sacrum,  occurring  below  the  sacro-iliac  symphysis,  are 
generally  followed  by  speedy  recoveries,  although  the  inward  dis- 
placement is  not  often  completely  overcome. 

By  introducing  a  finger  into  the  rectum,  the  lower  fragment  can  be 
easily  pressed  back  to  its  natural  position,  but  the  difficulty  consists 
in  finding  any  means  of  retaining  it  there  until  bony  union  is  effected. 
Judes  succeeded  to  his  satisfaction  with  a  wooden  cylinder,  which  he 
compelled  the  patient  to  wear  forty-five  days;  removing  it,  however, 
every  third  day,  in  order  to  cleanse  the  rectum  with  an  enema.  Ber- 
mond  introduced  first  a  linen  bag,  which  he  immediately  proceeded 
to  fill  with  lint;  but  during  the  night  it  became  necessary  to  remove 
it,  in  order  to  relieve  the  bowels  of  wind  and  stercoraceous  matter. 
He  now  substituted  a  silver  canula  covered  with  a  shirt,  which  latter 
he  filled  with  lint  in  the  same  manner  as  before.  This  was  retained 
without  much  inconvenience  nineteen  days:  having  only  been  re- 
moved once  during  this  time.  The  union  now  seemed  to  be  firm,  and 
the  apparatus  was  removed.  Plugging  the  rectum  in  this  manner 
may  be  necessary  whenever  the  inward  inclination  of  the  lower  frag- 
ment is  found  to  be  considerable,  but  not  otherwise  ;  ordinarily  it  will 
be  sufficient  to  lay  the  patient  upon  his  back,  with  a  firm  cushion 
above  the  point  of  fracture,  so  as  to  prevent  the  bed  from  pressing  in 
the  lower  fragment;  and  having  emptied  his  rectum  thoroughly  by 
an  enema  of  warm  water,  he  should  be'  placed  under  the  influence  of 
an  opiate  sufficiently  to  restrain  the  action  of  the  bowels  for  several 
days,  or  for  as  long  a  time  as  may  be  consistent  with  health  or  com- 
fort. To  the  same  end,  also,  the  diet  ought  to  be  light  and  dry; 
nothing  should  be  allowed  which  might  prove  laxative.  By  consti- 
pating the  bowels,  two  ends  may  be  gained.  We  shall  prevent  that 
frequent  action  of  the  sphincters,  which  might  tend  to  disturb  the 
union;  and  the  hardened  fseces,  by  their  accumulation  in  the  rectum, 
may  serve  to  press  back  the  lower  fragment  of  the  sacrum,  in  a 
manner  much  more  natural  and  quite  as  eflective  as  any  apparatus 
which  can  be  contrived. 

I  have  already  mentioned  a  case  of  separation  of  the  bones  at  the 
sacro-iliac  symphysis,  reported  by  Lente,  but  which  was  accompanied 
also  with  a  fracture  of  the  ilium  and  a  dislocation  of  the  hip.     Seve- 


COCCYX.  851 

ral  other  similar  examples  have  been  reported,  in  some  of  which  both 
ot'the- sacro-iliac  symphyses  have  been  separated,  or  displaced.  Such 
accidents  are  the  results  only  of  great  violence,  and  the  subjects  of 
them  seldom  recover. 

Dr.  J.  T.  Banks,  of  Griffin,  Ga.,  has  reported  one  example  of  com- 
plete recovery  in  an  adult  male,  in  which  the  right  sacro-iliac  sym- 
physis was  separated  "by  a  blow  received  upon  the  tuberosity  of  the 
ischium,  driving  the  ilium  up  an  inch  or  more,  causing  complete  pa- 
ralysis and  anaesthesia  of  the  right  leg  for  two  or  three  weeks ;"  motion 
of  the  hip  caused  also  severe  pain.  No  attempt  was  made  to  reduce 
the  bones,  but  union  occurred,  and  he  gradually  regained  the  use 
of  his  limb.^  In  a  few  instances  this  articulation  has  been  known 
to  give  way  during  labor,  while  the  symphysis  pubis  has  suffered 
little  or  no  diastasis;  and  in  these  cases  recovery  has  generally  taken 
place. 

In  nearly  all  the  traumatic  examples  reported,  the  diastasis  has 
been  accompanied  with  a  fracture  extending  parallel  with  the  margins 
of  the  synchondrosis;  and  it  is  for  this  reason  that  I  have  preferred  to 
consider  these  accidents  as  fractures,  rather  than  as  dislocations. 

§  6.  Coccyx. 

Cloquet  mentions  two  cases  as  having  come  under  his  notice,  one 
produced  by  a  kick,  and  the  other  by  a  flill.  In  the  latter  case  one 
thigh  and  both  legs  were  also  broken,  and  the  coccyx  having  become 
carious  in  consequence  of  the  fracture,  was  gradually  exfoliated.^ 

The  symptoms,  mode  of  diagnosis,  and  the  treatment  in  case  of  a 
fracture  of  the  coccyx  will  scarcely  demand  of  us  consideration  after 
having  treated  fully  of  these  points  in  their  relation  to  fractures  of 
the  sacrum. 

It  is  more  common,  however,  to  meet  with  examples  of  separations 
of  the  coccyx  from  the  sacrum,  which  may  be  regarded  in  some  cases 
as  veritable  fractures,  and  in  others  as  a  species  of  luxation. 

Due  to  the  same  causes  which  produce  fractures  of  the  coccyx  itself, 
its  symptoms  differ  only  in  the  increased  length  of  the  movable  frag- 
ment, and  its  consequent  greater  projection  in  the  direction  of  its 
displacement.  If  it  is  thrown  forwards,  as  it  usually  is,  the  rectum 
may  be  almost  or  completely  blocked  up  by  its  presence;  or,  if  it  is 
carried  backwards,  its  pointed  extremity  presses  almost  through  the 
skin. 

Its  mode  of  reduction  and  retention  is  the  same  as  in  fractures  of 
the  coccyx  and  sacrum. 

'  Banks,  Atlanta  Med.  and  Surg.  Journ.,  May,  18G6. 
2  Cloquet,  art.  Bussia,  of  Diet.  3d  vol. 


352 


FRACTURES    OF    THE    FEMUR. 


CHAPTER    XXVIIT. 


Fig.  110. 


FRACTURES  OF  THE  FEMUR. 

Development  of  Femur. — The  femur  is  formed  from  five  centre.^  of 
ossification :  namely,  one  for  the  shaft,  commencing  at  about  the  fifth 
week  of  foetal  life;  one  for  the  lower  end,  including  the  condyles,  com- 
mencing at  the  ninth  month  of  foetal  life ;  one  for  the  head,  com- 
mencing at  the  end  of  the  first  year  after  birth  ;  one  for  the  great  tro- 
chanter, commencing  during  the  fourth  year;  and  one  for  the  lesser 
trochanter,  commencing  between  the  thirteenth  and  fourteenth  years. 
None  of  these  epiphyses  are  joined  to  the  shaft  until 
after  puberty,  but  consolidation  is  generally  com- 
pleted at  the  twentieth  year.  The  order  in  which 
union  occurs  is  exactly  the  reverse  of  the  order  in 
which  ossification  commences,  the  lower  epiphysis 
being  the  first  to  exhibit  traces  of  ossification,  and 
the  last  to  unite. 

Division  of  Fractures. — Of  156  fractures  of  the  femur, 
not  including  gunshot,  which  have  been  recorded  by 
me,  63  belong  to  the  upper  third,  67  to  the  middle 
third,  and  26  to  the  lower  third;  or,  if  we  confine 
our  analysis  to  the  shaft  alone,  23  belong  to  the 
upper  third,  67  to  the  middle,  and  26  to  the  lower. 

The  femur  constitutes,  therefore,  a  striking  excep- 
tion to  the  rule  which  my  observations  have  estab- 
lished, that  in  the  case  of  the  long  bones  the  lower 
third  is  most  often  the  seat  of  fracture.  The  femur 
is  most  often  broken  in  its  middle  third,  and  gene- 
rally near  the  upper  end  of  this  third ;  that  is  to  say, 
above  its  middle. 

§  1.  Neck  of  the  Femur. 

Forty  of  the  whole  number  were  fractures  of  the 
neck,  either  intra-  or  extra-capsular.  The  youngest 
of  these  patients,  excepting  one  case  of  supposed  epi- 
physeal separation,  was  thirty-nine  years,  the  oldest 
eighty-four,  and  the  average  age  was  about  sixty. 

Seventeen  were  males  and  tvventy-three  females.     All  were  simple. 

Thirteen  were  believed  to  be  without  the  capsule,  and  sixteen  were 

believed  to  be  within  ;  the  remainder  were  undetermined. 

Surgeons  have  differed  in  their  opinions  as  to  the  relative  frequency 

of  fractures  of  the  neck  of  the  femur  within  or  without  the  capsule. 


Developmeut  of  Femur 
(From  Gray.) 


NECK,    WITHIN"    THE    CAPSULE.  353 

This  has  arisen,  no  doubt,  in  part  from  the  difficulty  and  probable 
inaccuracy  of  many  of  the  diagnoses.  Malgaigne,  who  has  adopted  a 
mode  of  deciding  this  question  which,  it  must  be  conceded,  is  much 
less  liable  to  error  than  simple  clinical  observation,  namely,  an  exa- 
mination of  cabinet  specimens,  finds  in  four  large  collections  sixty- 
one  intra-capsular  fractures,  and  only  forty-two  extra-capsular.  So 
that,  according  to  his  observations,  they  stand  in  the  proportion  of 
about  three  to  two  ;  the  intra-capsular  being  the  most  common.  On 
the  contrary,  N^laton  believes  that  extra-capsular  fractures  are  much 
the  most  common,  and  Bonnet,  of  Lyons,  affirms  that  they  constitute 
the  immense  majority.  Bonnet  made  four  dissections,  and  in  each 
case  he  found  the  fracture  extra-capsular.  This  testimony,  so  far  as 
it  goes,  is  positive,  but  the  number  is  not  sufficient  to  establish  any- 
thing more  than  a  probability  in  favor  of  the  greater  frequency  of 
extra-capsular  fractures. 

Clinical  observations  are  too  uncertain  to  be  made  available  in  so 
nice  a  question.  Cabinet  specimens  may  have  been  collected  for 
a  special  purpose,  and  this  is  well  known  to  have  been  the  fact  with 
the  celebrated  Dupuytren  collection,  the  specimens  in  which  constitute 
nearly  one-third  of  the  whole  number  referred  to  by  Malgaigne.  I 
allude  to  the  effort  which  was  made  while  the  controversy  was  pend- 
ing between  Dupuytren  and  Sir  Astley  Cooper  as  to  the  probability 
of  bony  union  in  intra-capsular  fractures,  to  accumulate  cabinet  speci- 
mens of  this  fracture ;  and  which  effort  extended  itself,  no  doubt,  both 
to  London  and  Dublin,  from  which  sources  alone  Malgaigne  has 
gathered  the  balance  of  his  figures.  In  Dr.  Mutter's  collection,  at 
Philadelphia,  I  think  there  are  only  three  examples  of  intra-capsular 
fracture,  to  seven  extra-capsular. 

Dr.  Reuben  D.  Mussey,  of  Cincinnati,  has  in  his  cabinet  twelve 
ex,amples  of  fractures  of  the  neck  of  the  femur  without  the  capsule, 
and  only  ten  within. 

We  ought,  therefore,  to  regard  the  question  of  relative  frequency 
as  still  undetermined. 

(a.)  Nech  of  the  Femur  ivithin  the  Capsule. 

Causes. — In  no  other  fractures  do  the  predisposing  causes  play  so 
important  a  part  as  in  fractures  of  the  neck  of  the  femur,  and  this 
whether  within  or  without  the  capsule  ;  indeed,  experience  has  shown 
that  without  the  concurrence  of  those  pathological  changes  which 
usually  accompany  old  age,  these  fractures  can  scarcely  occur.  Sir 
Astley  Cooper  thought  that  the  majority  of  fractures  of  the  neck  after 
the  fiftieth  year  were  intra-capsular;  but  Robert  Smith  has  given  us 
the  ages  of  sixty  persons  having  fractures  of  the  neck  of  the  femur, 
and  the  average  age  of  thirty-two  in  whom  the  fractures  were  within 
the  capsule,  is  sixty-two  years,  while  the  average  age  of  twenty-eight 
in  whom  the  fractures  were  extra-capsular,  is  sixty-eight  years.  Mal- 
gaigne has  referred  to  this  testimony  in  proof  of  the  inaccuracy  of  the 
opinion  held  by  Sir  Astley  Cooper;  but  I  trust  it  will  not  be  regarded 
impertinent  or  hypercritical  for  us  to  inquire  how  Mr.  Smith  became 


354 


FRACTURES    OF    THE    FEMUR. 


Fracture  withiu  the  capsule. 


possessed  of  the  ages  of  all  these  per- 
sons from  whom  these  specimens  were 
obtained;  for  more  than  half  of  the 
whole  number,  that  is,  just  thirty-two, 
have  their  ages  set  down  in  round  deci- 
mals, such  as  50,  60,  70,  &c.,  and  it 
would  be  easy  to  show  by  the  inevita- 
ble law  of  chances  that  this  could  not 
possibly  be  a  true  statement.  If  Mr. 
Smith  does  not  pretend  to  have  given 
the  ages  with  accuracy,  but  only  to  have 
arrived  as  near  to  the  truth  as  his  sources 
of  information  would  permit,  then  I  pro- 
test that  these  tables  do  not  constitute 
proper  evidence  in  relation  to  this  point ; 
and  until  better  evidence  is  furnished  I 
shall  continue  to  think,  with  Sir  Astley 
Cooper,  that  fractures  within  the  cap- 
sule belong  generally  to  an  older  class 
of  subjects  than  fractures  without  the 
capsule.  This  opinion,  confirmed  by  my  own  experience,  does  not, 
however,  as  Malgaigne  seems  to  think,  imply  that  fractures  within 
the  capsule  may  not  occasionally  occur  in  persons  much  younger  than 
the  average  limit,  namely,  under  fifty  years. 

It  is  also  believed  that  intra-capsular  fractures  are  more  frequent 
in  women  than  in  men. 

The  position  of  the  neck  of  the  femur,  and  the  great  thickness  of  the 
muscular  coverings,  render  its  fracture  from  a  direct  blow  a  very  rare 
circumstance;  indeed,  it  can  only  happen  as  the  result  of  gunshot 
accidents,  or  other  similar  penetrating  injuries. 

It  is  broken  therefore  usually  by  indirect  blows,  such  as  a  fall  upon 
the  bottom  of  the  foot,  upon  the  knee,  or  upon  the  trochanter  major ; 
or  by  muscular  action  alone,  as  has  sometimes  happened  with  very 
old  people,  who,  in  walking  across  the  floor,  have  tripped  upon  the 
carpet,  breaking  the  bone  in  the  effort  to  sustain  themselves.  We 
must  not  always  infer,  however,  because  the  patient  has  tripped,  that 
the  bone  was  broken  by  muscular  action ;  since  it  is  quite  as  likely 
that  the  fall,  consequent  upon  the  tripping,  has  occasioned  the  frac- 
ture;  and  we  ought  in  such  cases  to  make  a  careful  examination  of 
the  hip  over  the  trochanter  to  ascertain  whether  it  has  been  bruised, 
and  to  interrogate  the  patient  as  to  the  manner  of  the  fall. 

Rodet  has  attempted  to  show  by  a  series  of  experiments  made  upon 
the  dead  subject,  and  by  other  observations,  that  the  direction  in 
which  the  force  had  acted  will  determine  the  situation  and  direction 
of  the  fracture.  Thus  he  maintains  that  when  the  person  has  fallen 
upon  the  foot  or  knee,  the  fracture  will  be  intra-capsular  and  oblique  ; 
that  if  the  front  of  the  trochanter  receives  the  blow,  the  fracture  will 
be  intra-capsular  also,  but  transverse ;  if  the  back  of  the  trochanter  is 
struck,  the  fracture  will  be  partly  intra-  and  partly  extra-capsular ; 
and  if  the  person  falls  directly  upon  the  side,  or  receives  the  blow 


NECK,    WITHIN    THE    CAPSULE.  355 

fairly  upon  the  outer  side  of  the  trochanter,  the  fracture  will  be  en- 
tirely without  the  capsule.' 

Without  intending  to  give  my  unqualified  assent  to  these  proposi- 
tions so  ingeniously  maintained  by  Rodet,  I  am  nevertheless  prepared 
to  admit  their  general  accuracy;  and  especially  has  my  experience  led 
me  to  believe  that  falls  upon  the  feet  or  knees  in  most  cases  produce 
intra-capsular  fractures,  and  that  falls  upon  the  outside  of  the  hip,  or 
upon  the  great  trochanter,  generally  produce  extra-capsular  fractures. 
I  have  seen  also  the  intra-capsular  fracture  produced  by  so  slight  a 
cause  as  stepping  down  unexpectedly  two  or  three  inches  upon  an 
irregular  surface. 

PalliologTj.—l  have  already,  when  speaking  of  partial  fractures, 
expressed  my  conviction  of  the  possibility  of  a  partial  fracture,  or  a 
fissure  of  the  neck  of  the  femur,  and  I  have  referred  to  the  case  re- 
ported by  Dr.  J.  B.  S.  Jackson,  of  Boston,  as  having  determined  this 
question  beyond  all  possibility  of  a  doubt;  yet  its  occurrence  must  be 
regarded  as  an  exceedingly  rare,  and,  we  may  say,  improbable  event. 

It  is  much  more  common  to  meet  with  examples  of  complete  frac- 
ture of  the  neck  both  within  and  without  the  capsule,  unaccompanied 
with  a  rupture  of  either  the  periosteum  or  the  reflected  capsule.  Such 
was  the  fact  in  eight  cases  examined  by  Colles ;  in  three  of  which, 
however,  he  believed  the  fracture  not  to  have  been  complete,  but 
Robert  Smith  thinks  they  were  all  of  them  examples  of  complete 
fracture.^  Stanley  has  also  related  a  case  of  complete  separation  of  the 
bone  unaccompanied  with  laceration  or  injury  of  either  the  periosteum 
or  capsular  ligament.  This  was  in  the  person  of  a  man  aged  sixty 
years,  who  had  been  knocked  down  in  the  street.  On  being  admitted 
into  St.  Bartholomew's  Hospital,  shortly  after  the  injury,  he  com- 
plained of  pain  in  the  hip,  but  there  was  neither  shortening  nor  ever- 
sion  of  the  limb,  and  its  several  motions  could  be  executed  with 
freedom  and  power.  A  fracture  was  not  suspected ;  but  five  weeks 
after  this  he  died  of  inflammation  of  the  bowels.  The  dissection 
showed  a  fracture  extending  through  the  neck,  accompanied  with  a 
slight  bloody  effusion,  but  no  displacement  of  the  fragments  or  lacera- 
tion of  the  soft  parts.^ 

In  other  examples  the  bone  is  not  only  broken,  but  displaced  to 
such  an  extent  that  the  capsule  is  completely  torn  in  two. 

But  in  a  large  majority  of  cases  both  the  capsule  and  the  periosteum 
are  only  partially  torn  asunder. 

The  intra-capsular  fracture  is  generally  somewhat  oblique,  and  its 
direction  is  usually  from  above  downwards  and  from  within  outwards. 
Sometimes  its  direction  is  such  as  to  include  a  portion  of  the  head; 
occasionally  it  is  quite  transverse.  In  one  example  of  an  old  frac- 
ture I  have  seen  the  ends  dove-tailed  upon  each  other,  the  fracture 
having  a  double  obliquity,  and  not  admitting  of  displacement. 

There  may  occur  also  a  species  of  impaction,  the  lower  portion  of 

'  L'Experience,  March  14,  1844. 

2  Colles,  Dublin  Hosp.  Reports,  vol.  ii.  p.  339. 

2  Stanley,  Med.-Chir.  Trans.,  vol.  xiii. 


856 


FRACTURES    OF    THE    FEMUR. 


Fig.  112. 


Impacted  fracture  within  the  capsule. 


the  neck  entering  the  cancellous  structure 
of  the  head,  while  its  upper  portion  rides 
upon  the  articular  surface,  a  circumstance 
which  is  well  illustrated  by  the  annexed 
wood-cut  (Fig.  112),  copied  by  Mr.  Smith 
from  a  specimen  in  the  Dupuytren  Mu- 
seum at  Paris ;  or  the  impaction  may  occur 
without  any  degree  of  either  upward  or 
lateral  displacement. 

Mr.  Liston  says:  "  Even  in  children  sepa- 
ration of  the  head  of  the  bone  may,  on  good 
grounds,  be  supposed  occasionally  to  take 
})lace  ;"^  by  which  we  understand  him  to 
mean  that  a  separation  of  the  epiphysis 
which  completes  the  head  of  the  femur  may 
occur.  Mr.  South  relates  a  case  in  a  boy  ten 
years  of  age,  who  had  fallen  out  of  a  first- 
floor  window  upon  his  left  hip.  The  limb  was  slightly  turned  out, 
but  scarcely  at  all  shortened.  The  thigh  could  be  readily  moved 
in  any  direction  without  much  pain,  but  on  bending  the  limb  and 
rotating  it  outwards,  a  very  distinct  dummy  sensation  was  frequently 
felt,  apparently  within  the  joint,  as  if  one  articular  surface  had  slipped 
off' another.  This  was  regarded  by  both  Mr.  South  and  Mr.  Green  as 
an  example  of  epiphyseal  separation,  and  he  was  placed  upon  a  double- 
inclined  plane,  but  he  felt  so  little  inconvenience  from  it  that  he 
several  times  left  his  bed  and  walked  about.  We  have  no  informa- 
tion as  to  the  result  or  as  to  the  further  progress  of  the  case.^ 

A  girl,  £et.  18,  was  brought  before  Dr.  Parker,  of  New  York,  at  his 
surgical  clinic,  Nov.  1850,  who  had  been  injured  by  a  fall  upon  a 
curbstone,  when  eleven  years  old.  The  accident  was  followed  by 
suppuration  and  a  fistulous  discharge,  from  which,  however,  she  finally 
recovered,  but  with  the  foot  everted,  and  a  shortening  of  one  inch 
and  a  half.  "Flexion  and  rotation  of  the  joint  occasioned  no  incon- 
venience." Dr.  Parker  thought  this  circumstance  alone  sufficient  to 
distinguish  it  from  hip  disease  in  which  anchylosis  is  the  termination.^ 
At  a  meeting  of  the  Kappa  Lambda  Society,  held  in  New  York, 
March  25,  18-10,  Dr.  Post  mentioned  a  case  which  he  had  seen  in  a 
girl  sixteen  years  old,  who,  in  taking  a  slight  step  with  a  child  in  her 
arms,  made  a  false  movement,  and  feeling  something  give  way,  she 
was  obliged  to  lean  against  a  wall.  Dr.  Post  saw  her  the  next  day, 
when  he  found  the  affected  limb  one  inch  shorter  than  the  opposite 
one,  movable,  the  toes  turned  outwards,  no  swelling,  some  slight  pain 
at  the  upper  part  of  the  thigh.  The  trochanter  major  moved  with  the 
shaft.  There  was  also  crepitus.  From  the  age  of  the  patient,  and  the 
slight  amount  of  violence  by  which  the  injury  was  produced,  Dr.  Post 
thought  a  separation  of  the  epiphysis  of  the  head  had  taken  place. 


'  Liston,  Elements  of  Surgery,  Phila.  ed.,  1887,  p.  480. 

2  South,  Note  to  Chelius's  Surgery,  vol.  i.  p.  019. 

3  Parker,  Amer.  Med.  Gazette,  vol.  i.  p.  342,  Nov.  30,  1850. 


NECK,    WITHIN    THE    CAPSULE.  357 

The  extending  apparatus  was  applied,  but  the  limb  remains  from  a 
quarter  to  half  an  inch  shorter  than  its  fellow.^ 

Aug.  14,  1865,  Andrew  Leroj,  aet.  15,  in  attempting  to  escape  from 
the  House  of  Refuge,  fell  from  the  fourth  story.  On  the  following 
morning  he  was  admitted  into  my  wards,  at  Bellevue  Hospital,  I 
found  his  right  thigh  shortened  three-quarters  of  an  inch,  and  slightly 
abducted;  toes  everted.  Placing  him  under  the  influence  of  chloro- 
form, we  detected  a  dull  crepitus  in  the  vicinity  of  the  joint.  It  was 
unlike  the  crepitus  of  broken  bone.  With  fifteen  pounds  of  extension 
we  were  able  to  overcome  the  shortening  entirely,  and  to  put  the  limb 
in  position.  This  was  maintained  with  Buck's  apparatus.  At  the  end 
of  two  weeks,  however,  it  was  ascertained  to  be  shortened  half  an 
inch.  Four  more  pounds  were  then  added.  At  the  close  of  my  term 
of  service,  I  lost  sight  of  the  boy,  and  have  not  been  able  therefore  to 
verify  my  diagnosis;  but  I  believe  it  to  have  been  a  separation  of  the 
upper  epiphysis. 

These  lour  constitute  the  only  examples  of  this  accident  which  I 
find  reported  or  of  which  I  have  any  knowledge,  and  although  there 
may  be  much  reason  to  suppose  that  the  diagnosis  was  correct  in  each 
instance,  I  cannot  regard  any  one  of  them  as  actually  proven ;  nor 
can  I  admit  the  accident  as  fairly  established,  or  the  diagnostic  signs 
as  being  properly  made  out,  until  these  important  points  have  received 
the  confirmation  of  at  least  one  dissection. 

Symptoms. — Whether  the  limb  will  be  shortened  or  not  must  de- 
pend upon  whether  the  fragments  have  become  displaced  in  the  direc- 
tion of  the  axis  of  the  shaft  of  the  femur.  It  is  well  established  that 
in  this  fracture  the  broken  ends  frequently  remain  in  contact  for 
several  hours  or  days,  or  until  the  gradual  contraction  of  the  muscles 
or  the  weight  of  the  body  upon  the  limb  occasions  a  separation,  and 
that  consequently  there  is  often  at  first  no  appreciable  or  actual  short- 
ening of  the  limb.  To  determine,  however,  its  existence,  it  is  not 
sufficient  to  lay  the  patient  upon  his  back,  and  place  the  limbs  beside 
each  other ;  we  ought  also  to  measure  carefully  with  a  tape-line  from 
the  pelvis lo  the  leg  or  foot,  and  from  various  other  points,  until  we 
have  placed  this  question  beyond  a  doubt. 

If  shortening  occurs,  it  may  vary  from  one-quarter  of  an  inch  to 
two  inches,  or  even  more;  but  this  extreme  shortening  is  not  reached 
usually,  except  after  the  lapse  of  several  weeks  or  months,  when  the 
ligaments  have  gradually  given  way  under  the  weight  of  the  body  in 
walking,  or  not  until  the  neck  has  undergone  a  partial  or  almost 
complete  absorption. 

Sir  Astley  Cooper  has  stated  that  a  shortening  to  this  degree  may 
occur  at  once ;  but  Boyer,  Earle,  and  others  doubt  the  accuracy  of 
this  opinion,  and  Robert  Smith  declares  that  he  does  not  think  the 
capsule  would  admit  of  such  an  amount  of  immediate  displacement, 
unless  it  were  extensively  torn,  an  occurrence  which  he  thinks  very 
rare  indeed. 

With  this  qualification,  the  opinion  of  Mr.  Smith  does  not  differ 

'  Post,  New  York  Journ.  Med.,  vol.  iii.  p.  190,  July,  1840. 


358  FRACTURES    OF    THE    FEMUR. 

from  that  entertained  bj  Sir  Astlej,  who  only  admits  its  possibility 
as  a  rare  event;  in  a  large  majority  of  cases  the  shortening  does  not 
exceed  one  inch. 

Crepitus,  unlike  shortening,  is  generally  absent  when  the  displace- 
ment of  the  fragments  is  complete ;  but  under  no  circumstances  is  it 
easily  developed.  When  the  fragments  remain  in  apposition,  and  the 
femur  is  rotated  for  the  purpose  of  moving  the  broken  surfaces  upon 
each  other,  the  small  acetabular  fragment,  resting  in  a  smooth  cup-like 
socket,  and  holding  upon  the  opposite  fragment  by  denticulations  or 
by  the  untorn  periosteum,  or  capsule,  glides  about  in  obedience  to  the 
motions  of  this  latter,  and  no  crepitus  can  be  produced.  Nor  is  the 
difficulty  rendered  less  by  pressing  firmly  upon  the  trochanter,  as 
some  surgeons  have  recommended,  since,  while  this  pressure  tends, 
no  doubt,  to  fasten  the  upper  fragment  in  the  acetabulum,  it  tends 
much  more  to  fasten  the  broken  ends  together,  and  thus  defeats  the 
purpose  in  view.  When,  on  the  other  hand,  the  fragments  have  be- 
come completely  separated,  it  is  almost  impossible  to  bring  them  again 
into  contact.  The  limb  may,  perhaps,  be  easily  brought  down  to  the 
same  length  with  the  other,  but  it  must  by  no  means  be  inferred  that, 
consequently,  the  broken  ends  are  in  apposition.  It  is  almost  certain, 
indeed,  that  in  its  progress  downwards  the  trochanteric  fragment  has 
caught  upon  the  acetabular  fragment,  and  pushed  its  floating  and 
broken  extremity  downwards  before  it.  Under  these  circumstances, 
the  discovery  of  a  crepitus  must  be  accidental,  and  is  scared}'  to  be 
looked  for.  Sometimes,  however,  we  may  recognize  a  sound  not  un- 
like crepitus,  but  less  harsh,  produced  by  the  friction  of  the  trochan- 
teric fragment  against  the  rim  of  the  acetabulum  or  dorsum  of  the 
ilium. 

One  thing  we  ought  never  to  forget,  namely,  that  by  extraordinary 
efforts  to  obtain  a  crepitus  we  may  lacerate  the  capsule  or  produce  a 
displacement  of  the  fragments  which  we  never  can  remedy,  and 
which,  without  such  unwarrantable  manipulation,  might  never  have 
occurred. 

Eversion  of  the  foot  is  almost  uniformly  present  in  sotoe  degree, 
taking  place  immediately  or  more  gradually,  in  proportion  as  the 
fragments  become  displaced,  and  the  external  rotators  contract.  The 
opposite  condition  or  an  inversion  of  the  foot  is  occasionally  present, 
and  sometimes  also  the  foot  is  neither  turned  in  nor  out,  but  the  toes 
point  directly  forwards.  In  sixty  cases  of  fracture  of  the  neck  seen 
by  Cloquet  the  foot  was  never  turned  in,  and  Boyer  never  met  with 
such  an  example  in  all  of  his  immense  experience ;  but  Langstaftj 
Guthrie,  Stanley,  and  Cruveilhier  have  each  seen  one  example,  and 
Eobert  Smith  has  seen  two.^     I  have  myself  seen  one. 

The  explanation  of  the  fact  that  the  foot  is  usually  everted  is  not 
difficult.  In  the  case  of  an  intra-capsular  fracture  it  is  probably  due, 
first,  to  the  relative  friability  of  the  laminated  or  cortical  structure  on 
the  posterior  aspect  of  the  neck,  in  consequence  of  which  this  portion 
gives  way  more  readily  than  the  cortical  structure  on  the  anterior 

■  Robert  Smith,  op.  cit.,  p.  25.     A.  Cooper  by  B.  Cooper,  op.  cit.,  p.  151,  note. 


NECK,    WITHIN"    THE    CAPSULE, 


359 


aspect;  second,  to  the  natural  form  and  position  of  the  foot  and  leg, 
which  incline  them  to  fall  outwards  by  their  own  weight;  and  third, 
to  the  powerful  action  of  the  external  rotators,  which  are  so  feebly 
antagonized  upon  the  opposite  side.  In  the  case  of  an  extra-capsular 
impacted  fracture,  in  addition  to  the  second  and  third  causes  assigned 
as  influencing  the  position  of  the  limb  in  intra-capsulur  fractures, 
there  are  other  special  causes.  The  cortical  lamina  on  the  posterior 
aspect  of  the  neck  everywhere  more  frail  than  upon  the  anterior 
aspect,  becomes  greatly  weakened  as  it  approaches  the  trochanter  by 
dividing  itself  into  two  lamin;©,  one  of  which  penetrates  towards  the 
centre  of  the  bone,  and  the  other,  the  thinnest  of  the  t\vo,  being  scarcely 
thicker  than  a  sheet  of  paper,  forming  the  wall  of  the  bone  as  it 
becomes  continuous  with  the  trochanter. 


Fiij.  IVi 


Fisr.  114. 


Horizontal  section  of  neck  of  femnr. 
(From  Bigelow.) 


Extra-capsular  fracture,  with  inversion. 
(From  Bigelow.) 


This  delicate  papery  wall  easily  gives  way  under  the  application  of 
force,  while  the  anterior  wall  yields  only  partially,  constituting  thus  a 
sort  of  hinge  upon  which  the  rotation  of  the  thigh  is  performed.  It  is 
probable,  also,  as  suggested  by  M.  Robert,  that  the  angle  at  which  the 


860  FEACTURES  OF  THE  FEMUR. 

external  surface  of  the  trochanter  unites  with  the  neck  increases  the 
tendency  to  fracture  and  impaction  posteriorly. 

An  explanation  of  the  fact  already  stated,  that  in  rare  and  excep- 
tional cases  the  limb  is  inverted  or  the  toes  are  permitted  to  point 
directly  forwards,  has  been  thought  to  be  more  difficult.  Dr.  Bigelow 
has  had  an  opportunity  of  examining  a  specimen  taken  from  an  old 
woman  in  the  dissecting-room,  and  he  concludes  that  the  inversion 
was  due  to  the  extent  of  the  comminution,  which  had  separated  the 
walls  of  the  shaft  so  as  to  receive  in  the  interval  the  whole  neck,  in- 
stead of  the  posterior  wall  only,  as  commonly  occurs.  Dr.  Robert 
Smith,  of  Dublin,  cites  a  similar  case  verified  by  the  autopsy  ;  and  Dr. 
Bigelow  remarks  that  the  specimen  numbered  248,  in  the  Mutter 
museum,  at  Philadelphia,  presents  the  same  kind  of  impaction  without 
either  inversion  or  eversion. 

Fracture  of  the  neck  of  the  femur  within  the  capsule  is  not  usually 
attended  with  much  pain  when  the  patient  is  at  rest,  but  any  attempt 
to  move  the  limb  produces  intense  suffering,  and  especially  when  an 
attempt  is  made  to  rotate  the  limb  inwards,  or  to  carry  it  upwards 
and  inwards. 

Occasionally,  also,  during  the  first  few  days  or  hours  after  the 
fracture,  a  spasmodic  action  of  the  muscles  compels  the  patient  to  cry 
out  from  the  severity  of  the  pain  Avhich  it  produces.  At  first  the 
sufferer  is  unable  to  indicate  clearly  the  seat  of  this  pain,  or,  perhaps, 
it  is  diffused  and  uncertain  in  its  position;  but  after  a  time  he  is  able 
to  refer  it  chiefly  to  the  region  of  the  groin,  opposite  the  neck  of  the 
bone,  or  to  near  the  point  of  attachment  of  the  psoas  magnus  and 
iliacus  internus.  There  is  also  usually  in  this  region  a  great  degree 
of  tenderness  and  an  unusual  fulness. 

If  now  the  limb  be  seized,  and  extension  gradually  but  firmly 
applied,  it  will  soon  be  made  of  the  same  length  with  the  opposite 
thigh;  but,  the  moment  the  extension  is  discontinued,  the  shortening 
and  eversion  will  recur,  accompanied  with  pain,  and  perhaps  crepitus. 

The  trochanter  major  is  less  prominent  than  upon  the  opposite  side, 
and  if  eversion  of  the  limb  exists,  the  trochanter  may  be  felt  indis- 
tinctly upwards  and  backwards  from  its  usual  position.  The  patient 
having  been  placed  under  the  influence  of  an  anaesthetic,  we  may 
prosecute  the  investigation  still  farther,  and  by  rotating  the  limb  in- 
wards and  outwards  as  far  as  it  will  admit,  we  shall  notice  that  the 
trochanter  describes  the  arc  of  a  smaller  circle  than  in  the  opposite 
limb,  or  that  the  length  of  its  radius  has  been  shortened.  It  ought  to 
be  said  at  once,  however,  that  this  amount  of  manipulation  is  often  in- 
jurious, and  seldom  proper. 

The  patient  is  generally  unable  to  move  his  limb,  or  to  bear  the 
least  weight  upon  it;  but  many  examples  are  on  record  of  persons 
who  walked  some  distance  after  the  fracture  had  taken  place,  the 
capsule,  and  perhaps  also  the  periosteum,  not  being  torn,  and  conse- 
quently the  fragments  not  being  displaced  ;  or,  possibly,  it  was  at  first 
an  impacted  fracture. 

Finally,  after  having  examined  the  patient  as  well  as  we  are  able  to 
do,  in  the  recumbent  posture,  if  any  doubt  remains,  and  it  is  found 


KECK,    WITHIN    THE    CAPSULE.  361 

practicable  for  the  patient  to  be  elevated  upon  his  sound  foot,  this 
should  be  done.  The  broken  limb  can  now  be  examined  thoroughly 
on  all  sides,  and  a  more  accurate  opinion  formed  of  the  amount  of 
shortening  and  eversion.  It  will  be  especially  noticed  that  if  the 
weight  of  the  body  is  allowed  to  rest  upon  the  limb  in  the  slightest 
degree,  it  produces  insupportable  pain.  Dr.  Packard,  of  Philadelphia, 
informs  me  that  M.  Maisonneuve  has  lately  suggested  and  practised 
the  following  method  of  diagnosis  in  certain  doubtful  cases.  Lay  the 
patient  flat  on  his  belly,  and  then  bring  the  suspected  thigh  into  ex- 
treme extension  backwards.  If  it  is  not  broken,  the  neck  will  strike 
against  the  posterior  lip  of  the  acetabulum  and  the  progress  of  the 
thigh  in  this  direction  will  be  arrested.  If  it  is  broken,  it  can  be  car- 
ried backwards  much  farther. 

Of  this  method  as  a  means  of  diagnosis,  it  seems  proper  to  say  that, 
if  the  fragments  have  slid  past  each  other  and  the  limb  is  shortened, 
it  is  unnecessary  ;  and  if  they  are  still  in  apposition,  it  will  be  pretty 
certain  to  cause  displacement,  and  thus  do  irreparable  mischief. 

Prognosis. — The  question  of  bony  union  after  a  complete  fracture 
of  the  neck  of  the  femur  within  the  capsule  has  occupied  the  attention 
of  the  ablest  surgeons  and  pathologists  for  a  long  period  ;  and  while 
great  differences  of  opinion  have  been  expressed  as  to  the  probability 
of  the  occurrence,  and  as  to  the  value  of  the  testimony  on  the  one  side 
or  the  other,  very  few  have  ventured  to  deny  its  possibility. 

Among  these  latter  are  found,  however,  the  distinguished  names  of 
Cruveilhier,  CoUes,  Lonsdale,  and  Brausby  Cooper.  It  has  been 
repeatedly  affirmed,  also,  that  Sir  Astley  Cooper  taught  the  same  doc- 
trine, but  with  how  much  show  of  reason,  the  following  paragraphs 
from  his  own  pen  will  determine: — 

"  In  the  examinations  which  I  have  made  of  transverse  fractures  of 
the  cervix  femoris,  entirely  within  the  capsular  ligament,  I  have  only 
met  with  one  in  which  a  bony  union  had  taken  place,  or  which  did 
not  admit  of  a  motion  of  one  bone  upon  the  other.  To  deny  the  pos- 
sibility of  this  union,  and  to  maintain  that  no  exception  to  the  general 
rule  can  take  place,  would  be  presumptuous,  especially  when  we  con- 
sider the  varieties  of  direction  in  which  a  fracture  may  occur,  and  the 
degree  of  violence  by  which  it  may  have  been  produced.  For  example, 
when  the  fracture  is  through  the  head  of  the  bone,  with  no  separation 
of  the  fractured  ends  ;  when  the  bone  is  broken  without  its  periosteum 
being  torn ;  or,  when  it  is  broken  obliquely,  partly  within  and  partly 
externally  to  the  capsular  ligament,  I  believe  that  bony  union  may 
take  place,  although  at  the  same  time  I  am  of  opinion  that  such  a 
favorable  combination  of  circumstances  is  of  very  rare  occurrence. 
Much  trouble  has  been  taken  to  impress  the  minds  of  the  public  with 
the  false  idea  that  I  have  denied  the  possibility  of  union  of  fracture 
of  the  neck  of  the  thigh-bone,  and  therefore  I  beg  at  once  to  be  under- 
stood to  contend  for  the  principle  only,  that  I  believe  the  reason  that 
fractures  of  the  neck  of  the  thigh-bone  do  not  unite,  is  that  the  liga- 
mentous sheath  and  periosteum  of  the  neck  of  the  bone  are  torn 
through,  that  the  bones  are  consequently  drawn  asunder  by  the  mus- 
cles, and  that  there  is  a  want  of  nourishment  of  the  head  of  the  bone; 
24 


362  FRACTURES    OF    THE    FEMUR. 

but  I  can  readily  believe,  if  a  fracture  should  happen  without  the 
reflected  lisrament  beings  torn,  that  as  the  nutrition  would  continue,  the 
bone  might  unite;  but  the  character  of  the  accident  would  differ; 
the  nature  of  the  injury  could  scarcely  be  discerned,  and  the  patient's 
bone  would  unite  with  little  attention  on  the  part  of  the  surgeon. 

"  In  proof  of  the  correctness  of  my  opinion,  I  enumerated,  in  the 
early  editions  of  this  work,  forty-three  specimens  of  this  fracture,  in 
different  collections  in  London,  which  had  not  united  by  bone.  At 
the  present  day  these  might  be  multiplied,  were  it  necessary. 

"Such  has  been  the  accumulated  evidence  of  the  want  of  power  of 
the  neck  of  the  femur  to  unite  by  bone,  in  my  practice  of  forty  years, 
during  which  period  I  have  seen  but  two  or  three  cases  which  mili- 
tate against  this  opinion,  for  many  of  the  preparations  which  have 
been  brought  for  my  inspection  as  specimens  of  united  fractures  of 
this  part  have  proved  to  be  nothing  more  than  the  result  of  the 
changes  concomitant  with  old  age  ;  and  in  many  of  them  the  tAvo 
thigh-bones  of  the  same  subject  had  undergone  the  same  alteration  in 
texture  and  in  form."^ 

The  following  passages  from  a  communication  made  by  Sir  Astley 
to  the  London  Medical  Gazette,  for  the  25th  of  April,  1834,  are  equally 
pertinent: — 

"  I  find  in  a  report  of  the  Baron  Dupuytren's  lecture  that  he  attri- 
butes to  me  the  opinion  that  fractures  of  the  neck  of  the  thigh-bone, 
within  the  capsular  ligament,  not  only  '  never  unite,  but  that  it  is  im- 
possible that  they  should  unite  by  bone.' 

"  It  is  quite  true  that,  as  a  general  principle,  I  believe  that  those 
fractures  unite  by  ligament,  and  not  by  bone,  as  do  those  of  the  patella 
and  olecranon.  But  I  deny  that  I  have  ever  stated  the  impossibility 
of  their  ossific  union ;  on  the  contrary,  I  have  given  the  reason  why 
they  may  occasionally  unite  by  bone. 

"  The  following  are  my  words :  '  To  deny  the  possibility  of  their 
union,  and  to  maintain  that  no  exception  to  this  general  rule  may 
take  place,  would  be  presumptuous,' "  &;c.  &c. 

In  conclusion.  Sir  Astley  remarks :  "  I  should  not  have  given  you 
this  trouble,  nor  should  I  have  taken  it  myself,  but  for  the  respect  I 
bear  my  friend,  the  Baron  Dupuytren ;  for  although  I  have  already 
submitted  myself  to  be  misrepresented  by  many  individuals,  yet  I 
should  be  sorry  to  be  misunderstood  by  so  excellent  a  surgeon  and  so 
valuable  a  friend  as  Le  Baron  Dupuytren."^ 

Sir  Astley,  then,  so  far  from  denying,  frankly  admitted  the  possi- 
bility of  bony  union  when  the  neck  was  broken  within  the  capsule,  and 
explained  the  circumstances  under  which  he  believed  it  might  occur. 
The  true  point  in  dispute  was,  whether  certain  cabinet  specimens  were 
actually  examples  of  complete  fractures,  wholly  within  the  capsule, 
united  by  bone.     Some  of  them  Sir  Astley  thought  were  only  ex- 

1  Sir  Astley  Cooper  on  Dislocations  and  Fractures  of  the  Joints,  edited  by  Bransby 
Cooper,  Amer.  ed.,  p.  156. 

2  See  also  Sir  Astley's  letter  to  Prof.  Cox,  written  in  1835,  and  published  in  the 
Prov.  Med.  and  Surg.  Journ.  for  July  12,  1848,  New  York  Journ.  Med.  for  Sept. 
1848,  and  appendix  to  Cooper  on  Dis.  and  Frac,  Amer.  ed.,  1851,  p.  482. 


NECK,    WITHIISr    THE    CAPSULE.  363 

amples  of  cbronic  rheumatic  arthritis,  or  of  interstitial  and  progressive 
absorption.  Some  were  partial  rather  than  complete  fractures ;  others 
were  partly  within  and  partly  without  the  capsule ;  and  for  this  he 
was  accused  of  wilful  blindness  or  stupidity,  chiefly  by  those  who 
themselves  being  owners  of  these  rare  pathological  treasures,  might 
possibly  have  felt  somewhat  annoyed  at  seeing  their  value  thus  de- 
preciated, and  who,  no  doubt,  would  be  quite  as  apt  to  fall  into  blind- 
ness and  partisanship  as  Sir  Astley  himself.  The  truth  is,  however, 
that  although  the  claim  has  been  set  up  and  stoutly  maintained  for 
more  than  thirty  cabinet  specimens,  in  one  part  of  the  world  or 
another,  a  majority  of  these,  including  several  whose  claims  were 
urged  upon  Sir  Astley,  have  been  at  length  declared  by  all  parties 
unsatisfactory,  or  absolutely  fictitious,  and  only  a  fraction  of  the  whole 
number  continue  to  be  mentioned  by  any  surgical  writer  as  probable 
examples.^ 

Eobert  Smith  reduces  the  number  to  seven,  but  Malgaigne  recog- 
nizes only  three,  namely :  Swan's  case,  admitted  by  Sir  Astley  him- 
self; Stanley's  case,  and  one  specimen  in  the  Dupuytren  museum.  In 
neither  of  these  cases,  he  affirms,  has  the  neck  lost  anything  of  its. 
form  or  length  by  absorption,  from  which  we  are  to  infer  that  he 
would  reject  as  doubtful  all  such  specimens  as  had  undergone  these 
pathological  changes. 

Indeed,  I  think,  we  are  not  left  in  doubt  as  to  Malgaigne's  opinion 
upon  this  point.  Six  of  the  nineteen  cases  which  I  have  enumerated 
are  declared  by  him  to  resemble  much  more  rachitic  alterations  of  the 
neck  than  true  fractures  ;  and  yet  Robert  Smith  admits  three  of  the 
six  as  well-established  examples ;  but  as  to  the  precise  grounds  upon 
which  he  rejects  these  cases,  he  shall  speak  for  himself:  "And  it  is 
sufficient  that  we  consider  the  beautiful  drawings  designed  by  Sir 
Astley  Cooper,  to  illustrate  certain  varieties  of  the  alterations,  to  place 
us  on  our  guard  against  every  pretended  consolidation  which  presents 
itself,  accompanied  with  a  shortening  and  deformity  of  the  head  and 
neck.  When  fractures  unite  by  bone,  they  do  not  suffer  such  enormous 
losses  of  substance  which  it  would  become  necessary  to  admit  for  the 
neck  of  the  femur."^ 

'  The  following  European  surgeons  liave  claimed  to  have  in  their  possession, 
each,  one  example  :  Langstaff  (Med.-Chir.  Trans.,  vol.  xiii.  1827)  ;  Brulatour 
(Ibid.,  vol.  xiii.  1827);  Stanley  (Ibid,,  xviii.);  Swan  (Swan  on  Diseases  of  Nerves, 
p.  304);  Adams  (Todd's  Cyclop.,  p.  813);  Jones  (Med.-Chir.  Trans.,  vol.  xxiv.); 
Chorley  (Amesbury  onFrac,  p.  125);  Field  (Ibid.,  p.  128);  Soemmering  (Chelius's 
Surgery  by  South,  vol.  i.  p.  G21);  South  (Ibid.,  p.  621).  South  also  mentions 
another  example  as  being  in  the  museum  of  St.  Bartholomew's  Hospital.  This  is 
probably  Jones'  case,  which  Robert  Smith  says  is  preserved  in  this  museum,  and 
which  has  already  been  enumerated.  Bryant  (Memphis  Med.  Rec,  vol.  vi.  p.  108, 
from  British  Med.  Journ.,  March  14);  Fawdingtou  (Amer.  Journ.  Med.  Sci., 
vol.  XV.  p.  534,  from  London  Med.  Gaz.,  Aug.  16,  1834);  Harris  (Ibid.,  vol.  xviii. 
p.  246,  from  Dublin  Journ.,  Sept.  1885).  Robert  Hamilton  says  that  Prof  Tilanus 
showed  him  three  specimens  in  the  museum  of  the  Hospital  of  St.  Peter,  at  Amster- 
dam (Ibid.,  vol.  xxxi.  470,  from  Lond.  Med.  Gaz.,  Jan.  6,  1843).  Malgaigne  says 
there  are  three  specimens  in  the  Dupuytren  museum  which  have  been  described 
with  the  same  interpretation.  The  whole  number  claimed  by  transatlantic  surgeons 
is  therefore  nineteen. 

2  Malgaigne,  Traite  des  Fractures  et  des  Luxations,  torn.  i.  p.  678. 


364  FKACTURES    OF    THE    FEMUR. 

A  reference  to  Stanley's  case,  as  reported  bj  Robert  Smith,  will 
show  that,  contrary  to  Malgaigne's  statement,  this  was  also  shortened 
and  deformed,  and  that,  consequently,  according  to  his  own  rules  of 
exclusion,  it  also  must  be  rejected;  after  which  only  two  remain, 
namely  Swan's  case,  admitted  by  Sir  Astley  himself,  and  No.  188  of 
the  Du2:)uytren  museum, 

I  should  do  injustice  to  my  own  convictions,  moreover,  were  I  not 
to  refer  my  readers  to  the  very  judicious  criticism  upon  Mr.  Swan's 
case  made  by  Dr.  Johnson,  and  published  in  the  New  York  Journal 
of  Medicine,  vol.  ii.,  3d  series,  p.  295. 

Since  writing  the  above,  my  friend  Dr.  Voss,  of  this  city,  has  placed 
in  my  hands  an  elaborate  paper  on  this  subject,  from  the  pen  of  Dr. 
Edward  Zeis,  of  Dresden,  and  which  has  been  translated  by  Dr.  R. 
Newman,  Prosector  to  Chair  of  Surgery,  Long  Island  College  Hos- 
pital. Dr.  Zeis,  after  rejecting  all  other  European  specimens,  claims 
that  bony  union  has  occurred  within  the  capsule  in  a  specimen  now 
in  his  possession,  and  also  in  a  specimen  which  may  be  found  in  the 
pathological  cabinet  of  the  medico-chirurgical  academy  of  Dresden.^ 
I  regret  that  I  am  not  able  to  publish  these  cases  at  length,  as  well, 
also,  as  the  able  review  of  their  claims  sent  to  me  by  Dr.  Newman,  in 
which  Dr.  Newman  clearly  shows  that  Dr.  Zeis  has  completely  failed 
to  establish  the  correctness  of  his  opinions.  There  is  no  conclusive 
evidence  that  the  bones  were  ever  broken,  nor,  if  they  were  broken, 
that  the  fractures  were  entirely  within  the  capsule. 

On  this  side  of  the  Atlantic,  the  number  of  specimens  for  which 
the  honor  is  claimed  is  nearly  equal  to  the  original  number  in  Europe; 
but  they  have  not  yet,  all  of  them,  been  subjected  to  the  same  sifting 
process  as  their  foreign  congeners ;  and  it  remains  to  be  seen  how 
many  of  them  will  come  successfully  out  of  a  similar  fifty  years' 
contest. 

Three  of  the  specimens  belonged  to  Reuben  D.  Mussey,  late  Pro- 
fessor of  Surgery  in  the  Miami  Medical  College,  at  Cincinnati,  Ohio. 
He  has  himself  furnished  a  complete  history  and  description  of  the 
specimens,  accompanied  with  drawings.^  One  may  be  found  in  the 
Wistar  and  Horner  Museum,  at  Philadelphia;^  one  belongs  to  Willard 
Parker,  of  this  city  ;^  two  to  the  Albany  College  Museum;^  two  to  the 
Harvard  Medical  College,  Boston;^  one  to  the  Miitter  collection  (Spe- 
cimen B,  71);  one  to  Dr.  Pope,  of  St.  Louis.  Dr.  Sands,  of  this  city, 
has  also  lately  presented  a  supposed  example  to  the  New  York  Patho- 
logical Society.^ 

In  the  former  editions  of  this  book  I  have  examined  the  claims  of 
several  of  these  specimens  very  much  at  length;  but  as  new  specimens 
nre  every  now  and  then  being  presented  to  our  notice,  for  each  of 

1  Description  of  two  specimens  of  intra-capsular  fracture  of  the  neck  of  the  femur, 
and  union  by  callus,  by  Dr.  Edward  Zeis,  Dresden,  1864. 
^  Amer.  Jouru.  Med.  Sci.,  April,  1857. 
3  H.  H.  Smith's  Surgery,  p.  399. 
^  .Johnson's  paper  on  intra-capsular  fractures,  op.  cit. 
5  Trans.  New  York  State  Med.  Soc,  18r)8. 
^  Bigelow  on  Dislocation,  &c.  of  Hip,  1869,  p.  125. 
7  New  York  Med.  Rec,  June  1,  1869. 


NECK,  WITHIN"  THE  CAPSULE, 


365 


wliicli  special  claims  are  set  up,  and  inasrauch  as  no  practical  results 
are  likely  to  follow  upon  a  further  discussion  of  this  point,  or  upon  its 
definite  decision,  I  have  concluded  to  refer  those  of  my  readers  who  feel 
a  particular  interest  in  the  matter  to  either  one  of  my  earlier  editions, 
and  to  the  various  monographs  to  which  I  have  furnished  references. 

I  have  also  in  my  own  cabinet  a  femur  of  no  inconsiderable  preten- 
sions, belonging  clearly  to  that  class  of  specimens  recognized  by 
Eobert  Smith.  Its  neck  is  greatly  shortened,  and  this  surgeon  would 
regard  it,  I  think,  as  an  impacted  intra-capsular  fracture,  but  its  claim 
would  be  promptly  denied  by  Malgaigne,  on  account  of  the  absorption 
and  distortion  of  its  neck.     Its  history  is  as  follows: — 

About  the  year  1833,  Mrs.  Wakelee,  of  Clarence,  Erie  County,  IsTew 
York,  get.  68,  who  was  then  very  low  with  tubercular  consumption, 
and  so  ill  as  to  be  scarcely  able  to  walk  across  the  floor,  tripped  upon 
the  carpet  and  fell,  striking  upon  her  left 
side.     She  was  unable  to  rise,  but  was  laid 
upon  a  bed  by  her  son.  Dr.  Wakelee,  a 
very  intelligent  physician,  residing  in  the 
same  house,  who  did  not  suspect  a  frac- 
ture.    Dr.  Bissel  saw  her  on  the  following 
day,  and,  on  rotating  the  limb  outwards, 
he   says  that  he  discovered   a  crepitus. 
His  examination  was  greatly  facilitated 
by  her  exti'eme  emaciation. 

Mrs.  W.  was  placed  upon  a  double- 
inclined  plane,  with  apparatus  for  exten- 
sion, &c.,  and  left  in  charge  of  Dr.  Wakelee. 
On  the  fifth  day  the  splint  was  removed,  and 
from  this  time  no  dressings  of  any  kind 
were  applied.  The  reason  for  this  change 
of  treatment  was,  that  she  was  likely  to 
live  but  a  few  days,  in  consequence  of  the 
state  of  her  lungs,  and  that  such  confine- 
ment would  only  hasten  her  death.  Con- 
trary, however,  to  all  expectations,  she 
gradually  convalesced,  so  that  after  two 
or  three  years  she  could  walk  on  crutches, 
her  toes  turning  out  and  her  limb  becoming  somewhat  shortened. 
Four  years  after  the  accident  she  died,  and  Dr.  Bissel  obtained  from 
Dr.  Wakelee  the  specimen,  of  which  the  accompanying  drawing  is  a 
faithful  delineation. 

Within  the  last  few  years,  Dr.  Geo.  K.  Smith,  of  the  Long  Island 
College  Hospital,  has  made  a  most  valuable  contribution  to  our  know- 
ledge of  the  anatomy  and  pathology  of  the  hip-joint,  which  will 
explain  in  a  great  measure  the  discrepancies  of  opinion  which  at 
present  exist  among  surgeons  as  to  the  character  of  certain  specimens, 
and  may  hereafter  enable  us  to  decide  with  more  accuracy,  and  may 
lead  to  a  better  agreement  of  opinion. 

His  observations  prove  that  anatomists  have  not  hitherto  correctly 
described  the  attachment  of  the  capsule;  that  the  capsule  is  seldom,  if 


Vei'tical   section   of   Mrs.  Wakelee's 
femur,  acetabulum,  and  capsule. 


366 


FRACTURES    OF    THE    FEMUR. 


ever,  attaclied  at  the  same  point  in  different  persons,  while  it  is  as 
uniformly  found  attaclied  at  the  same  point  in  the  opposite  femurs  of 
the  same  person.  In  order,  therefore,  to  determine  whether  the  line 
of  fracture  in  any  given  specimen  was  without  or  within  the  capsule, 
we  must  always  compare  the  fractured  bone  with  its  congener,  and  not 
with  the  femur  of  another  person. 

He  has  further  shown  that  after  a  fracture,  and  the  consequent 
absorption  of  the  neck,  the  normal  position  of  the  capsule  is  almost 
constantly  changed;  so  that  its  present  attachment  does  not  declare 
what  were  the  points  of  its  attachment  before  the  fracture  occurred, 
and  finally  that  the  absorption  proceeds  unequally  and  irregularly, 
yet  with  great  rapidity,  in  the  two  fragments ;  and  as  the  bony  union, 
if  it  ever  takes  place,  probably  occurs  subsequent  to  the  arrest  of  the 
absorption,  the  line  of  union  cannot  in  itself  alone  determine  whether 
the  fracture  was  near  the  head  or  near  the  trochanters.^ 

It  seems  to  me  probable  that  under  certain  favorable  circumstances 
this  union  will  occur ;  these  favorable  circumstances  have  relation  to 
several  conditions,  such  as  age,  health,  degree  of  separation  of  the 
fragments,  laceration  of  the  periosteum  and  capsule,  treatment,  &c. 
Eobert  Smith  thinks  it  is  not  likely  to  occur  unless  the  fragments  are 

impacted,  but  Sir  Astley  Cooper, 
Fig.  116.  as  we  have  already  seen,  admitted 

its  possibility  whenever  the  re- 
flected capsule  and  the  periosteum 
were  not  torn,  and  at  the  same 
time  the  fragments  were  not  dis- 
placed. If  to  these  conditions 
we  were  to  add  moderate  but 
not  extreme  age,  with  good 
health,  we  can  see  no  sufficient 
reason  why,  under  judicious 
treatment,  bony  union  might  not 
occasionally  be  expected.  But 
such  a  combination  of  circum- 
stances is  probably  exceedingly 
rare;  and,  what  is  more  unfortu- 
nate, if  they  exist,  the  fracture  is 
not  likely  to  be  recognized,  and 
the  surgeon  will  fail  to  avail 
himself  of  those  advantageous 
coincidences  which  might,  if  un- 
derstood and  properly  treated, 
secure  a  bony  union.  Dupuy- 
tren  says,  when  the  fragments 
are  not  displaced  "  its  existence 
may  be  suspected,  but  cannot  be 
positively  asserted."  There  will  not  be  wanting,  however,  examples 
in  which  surgeons  will  believe  or  affirm  that  they  have  recognized 

1  Geo.  K.  Smith,  Insertion  of  the  capsular  ligament  of  the  hip-joint,  and  its  rela- 
tion to  intra-capsular  fracture.     Medical  and  Surgical  Reporter,  Philadelphia,  1863. 


Impacted  fracture   within 
Bigelow.) 


the   capsule.      (From 


NECK,    WITHIN    THE    CAPSULE, 


367 


the  fracture  and  wrought  the  cure.  I  have  heard  of  many  such  instances, 
and  Mr.  Smith  has  referred  to  one,  which  is  quite  pertinent,  as  having 
been  reported  in  the  Gazette  des  Hopitaux.  A  woman,  set.  64,  was 
treated  for  an  intra-capsular  fracture  of  the  neck  of  the  femur  at  one 
of  the  hospitals  in  Paris,  and  "  at  the  end  of  four  weeks  she  was  dis- 
charged perfectly  cured,  and  without  shortening."  We  fully  partake 
of  Mr.  Smith's  surprise  at  the  impudence  of  this  claim,  yet  we  do  not 
see  in  it  much  greater  improbability  than  in  Mr.  Swan's  case,  received 
by  both  Mr.  Smith  and  Sir  Astley  himself,  where  the  neck  was  found 
almost  wholly  united  by  bone  in  five  weeks,  although  the  woman  was 
80  years  old,  and  actually  dying  while  the  process  was  going  on ! 
Says  Dupuytren,  "  I  would  lay  it  down  as  a  general  principle  that  all 
fractures  of  the  neck  of  a  cylindrical  bone  should  be  kept  at  rest 
twice  as  long  as  ordinary  fractures  of  the  same  bone ;  and  even  after 
that  period  I  have  seen  displacement  take  place.  The  term  may, 
therefore,  be  lengthened  to  a  hundred  days,  or  even  longer  in  aged 
and  feeble  persons,  whose  powers  of  reparation  are  much  deteriorated." 

It  is  not  the  purpose  of  the  writer  to  describe  particularly  all  of 
the  accidents  or  pathological  conditions  with  which  these  fractures 
may  be  confounded.  It  is  sufficient  to  allude  to  them,  and  leave  to 
others  the  labor  of  a  complete  historical  record ;  but  I  am  tempted  to 
devote  a  paragraph  to  what  has  been  variously  termed  "  morbus  coxae 
senilis"  [Robert  Smith) ;  "  chronic  rheumatic  arthritis"  [Adams) ;  "  inter- 
stitial absorption  of  the  neck  of  the  thigh-bone"  [B.  Bell) ;  "  rheu- 
matic gout"  [Fuller)-^  and  by  others  "interstitial  and  progressive  ab- 
sorption ;"  but  the  exact  nature  and  cause  of  which  morbid  changes 
are  not  yet  fully  understood,  Mr.  Colles  does  not  think  this  partakes 
of  the  nature  of  rheumatism.  I  have  myself  a  specimen  of  what  has 
been  more  generally  called  chronic 
rheumatic  arthritis,  occurring  in  the 
knee-joint,  accompanied  with  a  flatten- 
ing and  eburnation  of  tiie  articular  sur- 
faces, and  Gulliver  has  shown  that 
similar  changes  of  form  in  the  neck  of 
the  bone  may  occur  in  tolerably  young 
persons. 

I  suspect  also  that  it  will  be  found  to 
occur  under  a  greater  variety  of  circum- 
stances, and  to  present  a  greater  variety 
of  forms,  than  have  yet  been  described  ; 
and  we  shall  perhaps  find  a  partial  ex- 
planation of  this  diversity  and  fre- 
quency in  one  single  circumstance, 
namely,  the  peculiar  anatomical  struc- 
ture of  the  neck.  The  rreck  of  the 
femur  stands  nearly  at  a  right  angle 
with  the  shaft,  or  at  an  angle  so  great 
as  that  the  weight  of  the  body,  even  in 
health,  has  the  effect  to  gradually  depress  the  head  below  the  top  of 
the  trochanter  major,  and  to  diminish  its  length.     This  is  seen  con- 


Fit?.  117. 


Seclion  of  a  sound  adult  femur. 


368 


FRACTURES    OF    THE    FEMUR. 


stantly  in  the  striking  change  of  form  which  occurs  between  child- 
hood and  old  age.  Noav,  if  from  any  cause  whatever,  such  as  a  blow 
upon  the  trochanter  or  upon  the  foot,  the  neck  or  head  is  made  to 
suffer,  and  inflammation,  or  perhaps  only  a  slight  degree  of  increased 


Fis?.  118. 


Chronic  rbenmatic  artliritis.  (Miller.) 

action  in  the  absorbents,  ensues,  resulting  in  an  equally  slight  soften- 
ing of  the  bony  tissue,  these  pathological  circumstances  may  end, 
sooner  or  later,  in  a  striking  change  of  form  in  the  neck  or  head. 
But  it  is  not  necessary  to  suppose  an  external  injury  to  explain  the 
occurrence  of  this  inflammation,  and  consequent  softening  of  the  bone ; 
a  scrofulous,  or  rickety,  or  tuberculous  constitution  may  occasion  it, 
and  we  see  no  reason  why  these  conditions  are  not  as  likely  to  lead 
to  a  change  of  form  here  as  in  the  bones  of  the  leg  or  of  the  spine. 
A  change  of  form  in  the  head  may  be  the  result  of  an  ulceration  of 
the  cartilage ;  and  a  change  of  form  in  the  neck,  of  ulceration  of  the 
neck.  Among  other  causes,  also,  "chronic  rheumatic  arthritis  may 
operate  in  a  large  proportion  of  those  examples  which  belong  to  ad- 
vanced life.  One  case,  reported  by  Gulliver,  would  seem  to  show 
that  a  deformity  may  occur  here  as  a  result  of  disease,  and  indepen- 
dently of  pressure,^  yet  it  is  plain,  from  the  direction  which  the  devia- 
tion of  the  head  and  neck  usually  takes,  that  pressure  performs  an 
important  part  in  the  causation. 

From  these  various  causes,  operating  in  these  diverse  ways,  we  shall 
have  the  different  deformities  enumerated  and  described  by  surgical 
writers.  The'  head  flattened,  irregularly  spread  out,  depressed  and 
polished  ;  the  neck  shortened  and  irregularly  thickened  and  expanded  ; 
the  trochanter  major  rotated  outwards  and  drawn  upwards ;   sinuous 


'  Gulliver,  Lond.  Med.-Chir.  Eev.,  vol.  xxxix.  p.  544. 


NECK,   WITHIN"    THE    CAPSULE,  369 

chasms  traversing  the  neck,  produced  by  ulceration;  and  finally, 
shortening  of  the  neck,  by  a  true  interstitial  absorption,  and  with 
little  or  no  increase  in  its  breadth,  the  trochanter  major  also  being 
rotated  outwards.  It  would  be  strange,  moreover,  if  the  interior  of 
these  bones  did  not  present  some  changes  in  structure,  such  as  have 
been  frequently  observed,  namely,  an  irregular  expansion  or  conden- 
sation of  the  cellular  tissue,  and  which  latter  might  easily  be  supposed, 
by  one  who  was  inattentive  to  all  of  these  circumstances,  to  indicate 
the  line  of  an  imaginary  fracture. 

The  following  example  will  illustrate  the  incipient  stage  of  one  class 
of  these  cases,  namely,  that  in  which  the  neck  is  not  only  shortened, 
but  its  surface  is  irregularly  seamed,  as  if  it  had  been  broken  and 
imperfectly  united, 

Wm.  Clarkson,  set.  43,  was  admitted  into  the  Toronto  Hospital,  C. 
"W.,  May  5,  1858,  with  tubercular  consumption,  of  which  he  died  on 
the  25th  of  the  same  month. 

He  had  been  under  the  care  of  Dr.  Scott,  and  it  having  been  noticed 
that  he  complained  of  his  right  hip  at  the  time  of  admission,  an  autopsy 
was  made  on  the  25th,  at  which  I  was,  through  the  courtesy  of  the 
house  surgeon,  permitted  to  be  present. 

We  examined  both  hip-joints,  and  found  the  neck  of  the  right  femur 
shortened,  especially  in  its  posterior  aspect.  At  the  junction  of  the 
head  with  the  neck,  posteriorly,  and  extending  about  half-way  around, 
the  boiie  was  carious,  and  so  far  absorbed  as  to  leave  a  sulcus  of  a  line 
or  two  in  depth,  and  of  about  the  same  width.  Adjacent  to  this,  also, 
the  bone  was  quite  soft,  yielding  under  the  slightest  pressure  of  the 
knife.  There  was  no  other  appearance  of  disease.  The  opposite 
femur  was  sound. 

The  hospital  record  furnished  the  following  account  of  his  case,  so 
far  as  the  injury  to  his  hip  was  concerned  : — ■ 

About  nine  months  before  admission,  then  laborinsr  under  the  ma- 
lady  of  which  he  finally  died,  he  received  a  blow  upon  his  right  tro- 
chanter, ever  since  which  he  had  been  lame,  and  suffered  pain  in  the 
region  of  the  hip-joint.  The  pain  was  felt  especially  in  the  groin,  when 
the  trochanter  was  pressed  upon,  or  when  the  sole  of  his  foot  was  per- 
cussed. The  thigh  was  slightly  flexed  ;  the  toes  a  little  everted  ;  and 
he  walked  with  some  halt. 

The  case  of  the  soldier.  Fox,  reported  by  Gulliver,  and  who  died  of 
tuberculosis,  presents  a  case  also  exactly  in  point,  but  illustrating  a 
later  stage,  or  the  completion  of  the  same  process. 

Of  the  precise  nature  of  the  changes  in  the  two  following  examples 
I  cannot  be  certain,  since  they  have  not  been  determined  by  dissection. 
They  will  serve,  however,  to  illustrate  the  usual  history  and  progress 
of  a  considerable  number  of  cases.  They  certainly  were  not  examples 
of  fracture. 

Ephraim  Brown,  when  twelve  years  old,  fell  from  a  tree  and  struck 
upon  his  right  foot.  Dr.  Silas  Holmes,  of  Stonington,  Ct.,  was  called. 
Of  the  particular  symptoms  at  this  time,  I  have  only  learned  that  the 
leg  was  not  shortened.  The  doctor  laid  a  plaster  u[)on  his  hip,  and 
left  him  without  any  further  treatment.     In  three  days  he  was  able  to 


370  FRACTUEES  OF  THE  FEMUR. 

walk  on  crutches;  in  three  weeks  he  walked  without  crutches,  and  in 
four  months  was  at  work  as  usual.  There  was  at  this  time  no  short- 
ening or  deformity  of  any  kind. 

Mr.  Brown  subsequently  enlisted  as  a  soldier  in  the  war  of  the 
American  Revolution,  and  experienced  no  difficulty  in  this  hip  until 
after  a  severe  illness  which  followed  upon  an  unusual  exposure,  when 
he  was  about  thirty-five  years  old.  At  this  period  the  leg  began  to 
shorten,  but  the  shortening  was  unaccompanied  with  pain  or  soreness. 

He  consulted  me,  July  17,  1845,  at  which  time  he  was  eighty-three 
years  old,  and  a  remarkably  strong  and  healthy-looking  man.  The 
shortening,  which  had  ceased  to  progress  some  years  before,  amounted 
at  this  time  to  two  and  a  half  inches. 

An  officer  in  the  United  States  army  addressed  to  me  the  following 
letter,  dated  Nov.  13,  1849  :— 

"  My  mother-in-law,  Mrs.  S.,  of  D.,  some  three  years  since  fell  down 
a  flight  of  stairs,  striking  on  her  side  upon  a  stone,  injuring  the  hip- 
joint  severely  ;  but,  upon  examination,  her  physician  declared  that 
there  was  neither  a  fracture  nor  a  dislocation,  and  said  that  she  would 
gradually  recover.  Something  like  one  year  since  the  injured  limb 
commenced  shortening,  so  that  she  can  now  barely  touch  her  toe  to 
the  floor  as  she  walks.  She  can  bear  but  little  weight  upon  it,  and 
is  compelled  to  use  a  crutch  or  a  cane  constantly.  So  much  time  has 
now  elapsed,  and  the  limb  is  so  little  better,  and  constantly  becoming 
shorter,  I  have  proposed  to  ask  your  opinion,"  &c. 

I  need  scarcely  say  that  I  had  no  hesitation  in  pronouncing  this  a 
case  of  chronic  inflammation  of  the  bone,  accompanied  with  softening 
and  gradual  change  of  form,  either  of  the  neck  or  head,  or  of  both. 

It  is  proper  that  I  should  state  briefly,  before  I  leave  this  subject, 
■  what  constitute  the  chief  difficulties  in  the  way  of  union  by  bone 
within  the  capsule. 

The  persons  to  whom  the  accident  occurs  are  generally  advanced  in 
life,  and  consequently  the  process  of  repair  is  feeble  and  slow. 

The  head  of  the  bone  receives  its  supply  of  blood  chiefly  through 
the  neck  and  reflected  capsule,  and  when  both  are  severed,  the  small 
amount  furnished  by  the  round  ligament  is  found  to  be  insufficient. 

When  the  fragments  are  once  displaced,  it  is  difficult,  as  I  have 
already  explained,  if  not  impossible,  to  replace  them. 

The  direction  of  the  fracture  is  generally  such,  that  the  ends  of  the 
fragments  do  not  properly  support  and  sustain  each  other  when  they 
are  in  apposition. 

The  fracture  is  at  a  point  where  the  most  powerful  muscles  in  the 
body,  acting  with  great  advantage,  tend  to  displace  the  broken  ends. 

Aged  persons,  who  are  chiefly  the  subjects  of  this  accident,  do  not 
bear  well  the  necessary  confinement,  and  especially  as  the  union 
requires  generally  a  longer  time  than  the  union  of  any  other  fracture ; 
so  that  a  persistence  in  the  attempt  to  confine  the  patient  the  requisite 
time  often  causes  death. 

Whether  the  absence  of  provisional  callus  as  a  bond  of  union,  and 
the  interposition  of  synovial  fluid  between  the  ends  of  the  fragments, 
constitute  additional  obstacles,  I  am  not  fully  prepared  to  say.     In  the 


NECK,   WITHIN    THE    CAPSULE. 


371 


opinion  of  many  surgeons  these  circumstances  constitute  very  serious, 
if  not  the  chief,  obstacles. 

It  remains  only  to  consider  what  is  the  usual  result  of  this  fracture. 

The  fragments,  more  or  less  displaced,  undergo  various  changes. 
The  acetabular  fragment  is  generally  rapidly  absorbed  as  far  as  the 
head ;  and  occasionally  a  considerable  portion  of  this  latter  disappears 
also  ;  while  the  trochanteric  fragment  appears  rather  as  if  it  had  been 
flattened  out  by  pressure  and  friction,  it  having  gained  as  much  gene- 
rally in  thickness  as  it  has  lost  in  length.  To  this  observation,  how- 
ever, there  will  be  found  many  exceptions.  Sometimes  the  trochanteric 
fragment  forms  an  open,  shallow  socket,  into  which  the  acetabular 
fragment  is  received ;  or  its  extremity  may  be  irregularly  convex  and 
concave,  to  correspond  with  an  exactly  opposite  condition  of  the  ace- 
tabular fragment.     (Fig.  119.) 

Ordinarily  the  two  fragments  move  upon  each  other,  without  the 
intervention  of  any  substance ;  but  often  they  become  united,  more  or 
less  completely,  by  fibrous  bands  (Fig.  120),  which  bands  may  be 


Fia:.  119. 


Fis?.  120. 


Fracture  of  cervix  femoris  within  capsule. 
Ununited.  Opposite  surfaces  irregularly  con- 
vex and  concave,  and  polished  ;  moving  slightly 
upon  each  other.  (From  a  specimen  in  the  pos- 
session of  Dr.  Crosby.) 


Mayo's  specimen.  United  by  ligament.  Patient 
lived  nine  months  after  the  accident.  The  tro- 
chanter minor  arrested  the  descent  of  the  head. 
(From  Sir  A.  Cooper.) 


short  or  long,  according  to  the  amount  of  motion  which  has  been 
maintained  between  the  fragments  while  they  are  forming,  or  to  the 
degree  of  separation  which  exists. 

The  capsular  ligaments  are  usually  considerably  thickened,  and 
elongated  in  certain  directions,  and  not  unfrequently  penetrated  by 
spicula  of  bone.  They  are  also  found  sometimes  attached  by  firm 
bands  to  the  acetabular  fragment.  * 

A  permanent  shortening,  either  with  or  without  eversion  of  the 


872 


FEACTURES    OF    THE    FEMUR. 


limb,  are  the  invariable  consequences  of  this  accident.  Indeed,  not  a 
few  succumb  rapidly  to  the  injury,  perishing  from  a  low,  irritative 
fever,  or  from  gradual  exhaustion,  within  a  month  or  two  from  the 
time  of  its  occurrence.  Says  Eobert  Smith  :  "  Our  prognosis,  in  cases 
of  fracture  of  the  neck  of  the  femur,  must  always  be  unfavorable.  In 
many  instances  the  injury  soon  proves  fatal,  and  in  all  the  functions 
of  the  limb  are  forever  impaired;  no  matter  whether  the  fracture  has 
taken  place  within  or  external  to  the  capsule — whether  it  has  united 
by  ligament  or  bone — shortening  of  the  limb  and  lameness  are  the 
inevitable  results." 

TreatmPMt. — In  case,  then,  of  a  complete  fracture  within  the  capsule, 
existing  without  laceration  of  the  reflected  capsule,  or  displacement  of 
the  fragments,  and  equally  in  case  of  a  fracture  at  the  same  point  with 
impaction,  the  treatment  ought  to  be  directed  to  the  retention  of  the 
bone  in  place,  by  suitable  mechanical  means,  for  a  length  of  time 
sufficient  to  insure  bony  union,  or  for  as  long  a  time  as  the  condition 
of  the  patient  will  warrant. 

The  means  which  are,  in  my  judgment,  best  calculated  to  fulfil  this 
important  indication,  are  complete  rest  in  the  horizontal  posture,  the 
limb  being  secured  by  the  same  apparatus  which  we  employ  with  so 
much  success  in  fractures  of  the  shaft.  In  fractures  of  the  neck,  how- 
ever, whether  within  or  without  the  capsule,  we  employ  no  coaptation 
splints;  and  the  amount  of  extension  ought  to  be  only  one-half  of 
that  generally  employed  in  fractures  of  the  shaft,  say  about  ten 
pounds.  The  long  side-splint,  with  a  foot-board,  to  prevent  eversion 
of  the  limb,  must  not  be  omitted.  In  my  hands,  and  in  the  hands  of 
my  expert  house  surgeons,  the  apparatus  has  undergone  so  many 
modifications  from  the  original  plans  of  Crosby  &  Buck,  that  I  shall 
hereafter  find  it  necessary  to  designate  it  as  my  own. 


Fisr.  121. 


Author's  apparatus  for  fractures  of  the  neck  of  the  femur. 

Another  apparatus  formerl}'-  employed  by  me,  in  fractures  of  the 
neck  of  the  femur,  but  for  which  I  have  lately  substituted  my  own, 
is  Gibson's  modification  of  Hagedorn's,  in  which  the  sound  limb  is 
first  secured  to  the  foot-board,  and  the  broken  limb  is  subsequently 
brought  down  to  the  same  point.  By  this  method,  as  by  my  own 
apparatus,  we  may  avoid  the  necessity  of  a  perineal  band,  which  is  so 
painful,  insupportable  often  when  the  fracture  is  at  the  neck. 

In  treating  this  fracture,  supposing  no  displacement  to  exist,  no 


NECK,    WITHIN    THE    CAPSULE, 


373 


extension  beyond  that  which  is  necessary  to  insure  perfect  quiet  can 
be  proper,  inasmuch  as  the  fragments  are  not  overlapped ;  and  they 
need  only  a  moderate  assistance  to  enable  them  to  maintain  their 
present  position  against  the  action  of  the  muscles.  Moreover,  if  the 
fragments  are  impacted,  violent  extension  would  disengage  them,  and 
I'ender  their  displacement  and  non-union  inevitable. 


Fiff. 132. 


Gibson's  modification  of  Hagcdorn's  splint. 

Fio;.  123. 


Gibson's  modified  splint  applied. 

I  am  prepared  to  affirm,  from  my  own  experience,  that  more  pa- 
tients will  endure  quietly  the  position  of  extension  for  a  length  of 
time  than  the  flexed  position,  whether  in  this  latter  the  patient  is 
placed  upon  his  side  or  upon  his  back. 

How  long  the  patient  will  submit  to  this,  or  to  any  other  mode  of 
securing  perfect  rest,  is  very  uncertain,  and  the  decision  of  this  ques- 
tion must  rest  with  the  individual  cases  and  the  good  sense  of  the 
surgeon.  Not  very  many  old  and  feeble  people  will  bear  such  con- 
finement many  days  without  presenting  such  palpable  signs  of  failure 
as  to  demand  their  complete  abandonment. 

Horizontal  extension  was  adopted  in  Jones'  case,  and  also  in  the 
case  reported  by  Fawdington,  and  is  said  to  have  been  successful.  In 
Brulatour's  case  the  limb  was  kept  extended  two  months;  inMussey's 
second  case  Hartshorne's  straight  splint  for  extension  remained  upon 
the  limb  eighty-four  days;  in  Bryant's  case  a  long  splint  was  used 
"  some  weeks." 

It  is  true,  however,  that  other  plans  of  treatment  seem  to  have  been 
equally  successful.  In  the  case  reported  by  Adams  the  limb  was 
placed  over  a  double-inclined  plane,  made  of  pillows,  five  weeks;  and 
in  Mussey's  third  example  the  limb  remained  in  the  same  position 
three  months.  Chorley  laid  his  patient  upon  the  sound  side,  with  the 
thighs  flexed,  for  a  space  of  two  weeks,  and  then  turned  him  upon  his 


374  FEACTUEES    OF    THE    FEMUR, 

back,  still  keeping  the  thighs  flexed.     At  the  end  of  six  weeks  he 
was  placed  in  a  straight  position,  &c. 

But  in  a  majority  of  the  examples  reported,  the  existence  of  the 
fracture  was  either  not  suspected,  or  bony  union  was  not  anticipated 
or  desired,  consequently  no  treatment  having  in  view  the  confinement 
of  the  broken  bone  was  adopted.  Yet,  the  success,  it  was  claimed, 
was  as  great  as  that  which  has  followed  either  of  the  other  plans, 
Harris'  patient  was  simply  laid  on  a  sofa.  Field's  patient,  who  broke 
the  neck  of  both  femurs  within  the  capsule  at  different  times,  was  in 
each  case  left  without  treatment,  except  that  she  lay  upon  her  bed, 
Mussey  himself  removed  all  dressings  from  Dr.  Dalton's  patient  on  the 
eighteenth  day,  and  placed  him  upon  his  feet,  and  Dr,  Wakelee  re- 
moved the  apparatus  from  his  mother  on  the  fifth  day. 

Nor  are  we  without  evidence  that  the  careful  and  judicious  appli- 
cation of  splints,  long  continued,  and  employed  under  the  most  favor- 
able circumstances,  will  sometimes  fail.  The  two  following  cases 
confirm  these  remarks.  The  first  occurred  in  the  practice  of  Dr, 
James  E.  Wood,  of  this  city:  "  M.  J.,  a  young  lady,  set.  16  years;  of 
vigorous  constitution ;  perfectly  free  from  any  constitutional  taint, 
either  of  scrofula,  syphilis,  or  cancer,  was  caught  between  the  wheels 
of  two  carriages,  the  one  stationary,  the  other  in  motion.  The  blow 
was  received  directly  on  the  trochanter  major  of  the  right  side.  The 
symptoms  which  presented  themselves  showed  conclusively  that  there 
was  a  fracture.  There  was  shortening,  loss  of  voluntary  motion,  and 
aversion ;  by  placing  the  finger  on  the  trochanter  major,  and  the 
thumb  in  the  groin,  a  well-marked  crepitus  could  be  felt  on  extension 
and  rotation  being  made.  There  was  no  laceration  or  other  compli- 
cation of  the  injury.  She  was  placed  on  Amesbury's  splint,  with  side 
splints  accurately  adjusted,  and  every  precaution  taken  to  insure  a 
perfect  union.  The  limb  was  kept  on  this  splint  without  being  dis- 
turbed for  six  weeks.  At  the  end  of  that  time  it  was  taken  from  the 
splint,  and  examined  with  care.  The  signs  of  fracture  still  remained; 
the  limb  was  replaced  on  the  splint,  and  the  dressings  as  before ; 
everj'thing  was  attended  to  in  the  genei-al  management  of  the  case 
which  the  doctor  thought  would  be  conducive  to  perfect  union.  The 
patient  was  kept  for  three  weeks  longer  on  the  splint,  Avhich  was  then 
removed.  It  was  found  that  there  was  no  union.  Patient  lived  for 
three  years,  and  was  so  lame  that  she  was  always  obliged  to  use  a 
crutch  in  walking.  At  the  expiration  of  three  years  she  died  of  an 
acute  disease, 

"  On  examination  of  the  cervix  femoris,  it  was  found  that  there  had 
been  a  transverse  fracture  of  the  bone  just  at  the  junction  of  the  head 
and  neck.  The  head  of  the  bone  was  still  attached  to  the  acetabulum 
by  the  ligamentum  teres.  The  process  of  absorption  had  been  going 
on,  and  the  head  of  the  bone  had  already  been  absorbed  below  the 
level  of  the  acetabulum,  and  what  remained  was  soft  and  spongy, 
easily  broken  with  the  handle  of  the  scaljiel.  The  neck  of  the  bone 
was  rounded  off'  and  covered  with  a  fibrous  deposit.  This  was  not  a 
case  of  diastasis,  as  has  been  suggested  by  an  eminent  surgeon,  who 


NECK,    WITHIN    THE    CAPSULE.  375 

judged  simply  from  the  age  of  the  patient.     She  was  full  sixteen  Avhen 
the  accident  happened,  and  over  nineteen  when  she  died." 

The  second  was  in  the  person  of  a  man,  set.  25  years,  who  was  at 
the  time  of  the  accident  robust  and  in  good  health.  "  He  was  dancing 
at  his  sister's  wedding;  while  cutting  a  pigeon  wing,  he  struck  the 
foot  upon  which  he  was  resting  from  under  him,  and  fell,  striking 
directly  upon  the  trochanter  major.  He  was  unable  to  rise ;  a  car- 
riage was  called,  and  he  was  taken  directly  to  the  New  York  Hospital. 
There  he  came  under  the  charge  of  Dr.  J.  Kearney  Rodgers.  A  frac- 
ture was  immediately  diagnosticated,  and  for  a  few  days  he  was  kept 
on  the  double-inclined  plane.  The  straight  splint  was  then  used,  and 
the  dressings  kept  up  for  six  weeks;  at  the  end  of  that  time  they  were 
taken  offj  and  the  limb  examined ;  there  was  no  union.  The  limb 
was  continued  in  the  straight  splints  for  three  weeks  longer,  and  again 
examined  ;  there  was  still  no  union.  The  patient  was  again  replaced 
in  the  straight  splint  for  two  weeks  longer,  but  no  union  occurred. 
At  the  end  of  three  months  from  his  admission  he  was  discharged;  he 
was  in  good  health,  but  so  lame  that  he  was  obliged  to  use  two  crutches 
in  walking.  After  his  discharge  the  patient  became  very  intempe- 
rate ;  and  in  the  course  of  a  few  weeks  he  applied  for  admission  to' 
Bellevue  Hospital.  He  was  much  debilitated,  and  had  an  exhausting 
diarrhoea.  Shortly  after  his  admission  an  immense  abscess  formed 
over  the  joint,  which  discharged  profusely.  The  man  died  shortly 
after  from  exhaustion,  and  the  specimen  came  into  Dr.  Van  Buren's 
hands,  the  patient  having  been  in  his  service.  Dr.  Van  Buren  was 
aware  of  the  patient's  previous  history,  the  treatment,  etc.,  at  the  New 
York  Hospital,  and  a  careful  examination  was  made. 

"  The  capsular  ligament  was  destroyed  entirely  by  the  suppurative 
process;  there  was  a  formation  of  callus  upon  the  trochanter  major; 
the  ligamentum  teres  was  entirely  absorbed;  the  head  of  the  bone  was 
spongy,  as  if  worm-eaten ;  the  direction  of  the  fracture  was  oblique, 
commencing  just  at  the  articulating  surface  of  the  head  and  ending 
just  within  the  capsule;  the  upper  end  of  the  shaft  of  the  bone  showed 
this  same  appearance  that  was  marked  in  the  head.  These  points  are 
beautifully  shown  in  the  specimen  at  the  present  time.  The  opinion 
of  Charles  E.  Isaacs,  M.D.,  the  able  Demonstrator  of  Anatomy  of  the 
University  Medical  College,  is,  that  this  fracture  was  entirely  within 
the  capsule.'"  The  bone  may  be  seen  in  the  museum  of  the  University 
Medical  College,  New  York. 

Such  equal  results  from  opposite  plans,  and  unequal  results  from 
similar  plans  of  treatment,  are  not  calculated  to  increase  our  faith  in 
the  testimony  which  most  of  the  foregoing  examples  are  supposed  to 
furnish  of  the  possibility  of  bony  union.  On  the  contrary,  they  can- 
not fail  to  suggest  a  doubt  as  to  whether  some  of  them,  at  least,  were 
not  inaccurately  diagnosticated. 

But  admitting  that  they  were  not,  the  testimony  which  they  furnish 
in  relation  to  treatment  is  too  inconclusive  to  be  made  available  for 

'  Johnson,  op.  cit.,  pp.  13-15. 


376  FRACTURES    OF    THE    FEMUR. 

instruction,  and  we  are  still  at  liberty  to  adopt  that  which  seems  most 
rational,  without  reference  to  the  experience  of  others. 

The  reasons  why  I  would  prefer  mj  own  plan  have  already  been 
stated  in  part,  to  which  I  will  now  add,  that  if  an  error  should  occur 
in  the  diagnosis — if  it  should  prove  finally  to  have  been  a  fracture 
without  the  capsule — then  this  treatment  would  be  correct,  and  no 
injury  would  come  to  the  patient  from  the  error  in  diagnosis;  but  if 
we  adopt  Sir  Astley  Cooper's  suggestion,  namely,  to  get  the  patient 
upon  crutches  as  soon  as  possible,  perhaps  as  soon  as  fourteen  days, 
an  error  in  diagnosis  might  be  followed  by  the  most  disastrous  con- 
sequences. 

(b.)  Neck  of  the  Femur  without  the  Cajisule. 

Causes. — Like  fractures  within  the  capsule,  these  also  occur  most 
frequently  in  advanced  life ;  age  may  therefore  be  regarded  as  the 
grand  predisposing  cause. 

As  to  the  immediate  causes,  we  have  already  mentioned  in  the  pre- 
ceding section  that  fractures  without  the  capsule  seem  to  be  the  result 
.  generally  of  falls  or  of  blows  received  directly  upon  the  trochanter ; 
occasionally,  also,  they  are  produced  by  falls  upon  the  feet  or  upon 
the  knees. 

Pathology. — These  fractures  may  occur  at  any  point  external  to  the 
capsule,  but  generally  the  line  of  fracture  is  at  the  base,  corresponding 
very  nearly  with  the  anterior  and  posterior  inter-trochanteric  crests. 
Almost  invariably  the  acetabular  penetrates  the  trochanteric  fragment 
in  such  a  manner  as  to  split  the  latter  into  two  or  more  pieces.  The 
direction  of  the  lesions  in  the  outer  fragments  preserves  also  a  remark- 
able uniformity;  the  trochanter  major  being  usually  divided  from  near 
the  centre  of  its  summit,  obliquely  downwards  and  forwards  towards 
its  base,  and  the  line  of  fracture  terminating  a  little  short  of  the  tro- 
chanter minor,  or  penetrating  beneath  its  base  ;  while  one  or  two  lines 
of  fracture  usually  traverse  the  trochanter  major  horizontally. 

In  an  examination  of  more  than  twenty  specimens,  I  have  noticed 
but  two  or  three  exceptions  to  the  general  rules  above  stated. 

In  Dr.  Miitter's  collection,  specimen  marked  B  115  is  not  accompa- 
nied with  either  impaction  or  splitting  of  the  trochanteric  fragment; 
but  the  neck  having  been  broken  close  to  the  inter-trochanteric  lines, 
has,  apparently,  slid  down  upon  the  shaft  about  one  inch,  at  which 
point  it  is  firmly  united  by  bone. 

Dr.  Neill  has  also  a  specimen  of  fracture  at  the  same  point,  but  with- 
out union  of  any  kind,  in  which  no  traces  remain  of  a  fracture  of  the 
trochanters.  The  acetabular  fragment  has  moved  up  and  down  upon 
the  trochanteric  until  it  has  worn  for  itself  a  shallow  socket  three 
inches  and  a  half  long;  the  approximated  surfaces  being  smooth  and 
polished  like  ivory. 

The  trochanter  major  is  usually  turned  backwards,  the  shaft  of  the 
femur  being  rotated  in  this  direction,  the  same  as  is  usually  observed 
in  other  fractures  of  the  neck  of  the  femur.  I  have  seen  one  exception 
to  this  general  rule  in  a  specimen  belonging  to  Dr.  Mutter  (No.  29); 


NECK,    WITHOUT    THE    CAPSULE, 


377 


the  trochanter  in  this  instance  is  turned  forwards,  so  that  the  neck  is 
shorter  in  front  than  behind. 


Fio-.  124. 


Fio;.  125. 


Impacted  extra-capsular  fractures.     (R.  Smith,  and  Erichsen.) 


The  upper  fragments  of  the  trochanter  major,  whenever  the  lines  of 
fracture  are  transverse,  are  generally  inclined  inwards  toward  the  neck, 
as  if  displaced  in  this  direction  by  the  force  of  the  blow,  or  perhaps 
by  the  resistance  offered  by  certain  muscles  and  ligamentous  bands 
which  find  an  insertion  upon  its  summit. 

The  neck  is  found,  in  most  cases,  standing  inwards  at  nearly  a  right 
angle  with  the  shaft,  the  head  being  much  more  depressed  than  the 
outer  extremity  of  the  neck;  in  consequence  of  which  the  lower  margin 
of  its  broken  extremity  is  driven  much  deeper  into  the  trochanteric 
fragment  than  is  the  upper  margin. 

Malgaigne  believes  that  impaction,  with  consequent  fracture  of  the 
trochanters,  is  never  absent  in  true  extra-capsular  fractures,  unless  it 
be  in  that  very  unusual  variety  in  which  the  trochanter  forms  a  part 
of  the  inner  fragment  (fractures  through  the  trochanter  major  and 
base  of  the  neck).  Robert  Smith  entertains  the  same  opinion,  although 
Malgaigne  does  not  seem  to  have  so  understood  him.  I  cannot  agree, 
however,  with  either  of  these  gentlemen  that  the  rule  is  so  invariable, 
since  I  am  confident  that  no  such  splitting  has  occurred  in  either  of 
the  two  specimens  to  which  I  have  referred  as  belonging  respectively 
to  Drs.  Miitter  and  Neill.  It  is  true  these  are  both  old  fractures,  and 
to  some  extent  the  signs  of  fracture  may  have  become  obliterated,  but 
in  Mutter's  specimen  an  abundant  callus  indicates  plainly  enough 
where  the  shaft  separated  from  the  neck,  while  the  trochanter  major 
is  smooth  as  in  its  normal  condition,  nor  does  its  summit  incline 
either  way  from  its  usual  position.  Neill's  specimen,  though  less 
satisfactory,  does  not  fail  to  convince  me  that  neither  impaction  nor 
splitting  of  the  trochanters  ever  occurred. 

It  is  certain,  however,  that  impaction  and  comminution  of  the  outer 
25 


378  FKACTURES    OF    THE    FEMUR. 

fragment  are  very  constant;  and  that,  wliether  the  fracture  is  produced 
by  a  fall  upon  the  feet  or  upon  the  trochanter  major.  But  the  impac- 
tion does  not  necessarily  continue;  sometimes,  indeed,  it  does,  and 
the  position  of  the  limb,  whatever  it  may  be  at  the  moment,  remains 
unalterably  fixed  ;  either  very  little  or  considerably  shortened,  accord- 
ing to  the  degree  of  impaction ;  rotated  outwards  or  inwards,  or  in 
neither  direction,  perhaps,  according  to  the  direction  of  the  force  and 
the  amount  of  comminution.  In  other  cases,  owing  to  the  extreme 
comminution,  and  to  the  wide  separation  of  the  trochanteric  fragments, 
or  to  the  contraction  of  the  muscles  inserted  into  the  top  of  the  femur, 
or  to  the  weight  of  the  body  in  attempts  to  walk,  or  to  injudicious 
handling  on  the  part  of  the  surgeon,  such  as  forcible  rotation,  by  which 
the  neck  is  made  to  act  as  a  lever,  and  to  actually  pry  the  fragments 
apart,  or  to  violent  extension,  by  which  the  impaction  is  overcome — 
owing  to  some  one  or  several  of  these  causes  it  often  happens  that  the 
fragments  separate,  and  the  leg  becomes  immediately  more  shortened, 
movable,  and  more  inclined  to  rotate  outwards. 

Symptoms. — The  symptoms  which  indicate  a  fracture  of  the  neck 
of  the  femur  without  the  capsule,  are  pain,  mobility,  crepitus,  short- 
ening and  eversion  of  the  limb.  The  trochanter  major  is  not  as  pro- 
minent as  upon  the  opposite  side  ;  and,  especially  where  the  fragments 
are  not  impacted,  but  are  completely  separated,  it  rotates  upon  a 
shorter  axis.  There  are  also  several  other  signs  to  which  I  shall  refer 
when  considering  the  differential  diagnosis. 

The  pain  and  tenderness,  accompanied  sometimes  with  swelling  and 
discoloration,  are  situated  most  often  in  front  of  the  neck  of  the  bone. 

Mobility  exists  in  a  majority  of  cases,  even  when  the  fragments  are 
impacted  ;  that  is,  the  limb  can  be  moved  pretty  easily  in  any  direc- 
tion by  the  surgeon,  but  not  without  producing  pain  or  provoking 
muscular  spasms,  yet  the  patient  himself  is  unable  to  move  the  limb 
by  his  own  volition,  or  he  can  only  move  it  slightly. 

Crepitus  is  present  whenever  there  exists  a  moderate  but  not  com- 
plete impaction.  It  is  also  present  generally  when,  the  trochanteric 
fragment  having  been  extensively  comminuted  and  loosened,  the 
impaction  becomes  excessive;  and  it  is  only  absent  when  the  impac- 
tion is  such  that  the  fragments  are  completely  and  firmly  locked  into 
each  other. 

A  shortening  is  inevitable,  at  least  in  all  cases  accompanied  with 
either  temporary  or  permanent  impaction,  and  we  have  seen  that  one 
of  these  conditions  seldom  fails.  According  to  Sir  Astley  Cooper  the 
shortening  varies  from  half  an  inch  to  three-quarters  of  an  inch,  but 
Eobert  Smith  has  established  the  following  distinction.  When  the 
fracture  is  extra-capsular  and  impacted,  that  is,  when  it  remains  im- 
pacted, the  shortening  is  only  moderate,  varying  from  one-quarter  of 
an  inch  to  one  inch  and  a  half;  in  fourteen  cases  measured  by  him 
the  average  was  a  fraction  over  three-quarters  of  an  inch ;  but  when 
it  does  not  remain  impacted  it  ranges  from  one  inch  to  two  inches 
and  a  half;  indeed,  Mr.  Smith  mentions  one  example  in  which  the 
shortening  reached  four  inches,  and  forty-two  cases  gave  an  average 
shortening  of  something  more  than  one  inch  and  a  quarter. 


NECK,  WITHOUT  THE  CAPSULE, 


379 


Eversion  of  the  toes  is  very  constant;  but  in  a  Fig.  137. 

few  instances  upon  record  the  toes  have  been 
found  turned  in,  or  even  directed  forwards. 
During  the  winters  of  18(34  and  'Qo,  I  found  a  case 
of  this  kind  in  my  wards  at  Bellevue  Hospital. 
In  the  specimen  referred  to  as  being  found  in  Dr. 
Mutter's  collection,  with  an  inward  or  forward 
rotation  of  the  trochanter  major,  the  same  relative 
position  of  the  whole  limb  must  have  existed  ; 
and  in  my  remarks  on  fractures  of  the  neck  within 
the  capsule,  I  have  referred  to  several  examples, 
some  of  which  were  probably  exti'a-capsular. 

The  trochanter  major  usuall}^  seems  depressed 
or  driven  in,  and  when  the  two  main  fragments 
are  completely  separated,  if  the  limb  is  rotated, 
the  trochanter  will  be  found  to  turn  almost  upon 
its  own  axis,  or  upon  a  very  short  radius. 

In  enumerating  the  signs  of  extra-capsular  frac- 
ture, it  will  be  seen  that  I  have,  with  only  slight 
variations,  repeated  the  signs  of  a  fracture  within 
the  capsule.  It  will  become  necessary,  therefore, 
to  indicate,  as  far  as  possible,  a  differential  diag- 
nosis. And  without  pretending  that  all  of  the 
difierential  signs  which  I  shall  enumerate  are  thoroughly  established, 
or  that  in  every  case,  even  after  a  careful  grouping  of  all  the  symp- 
toms, a  satisfactory  diagnosis  can  be  made  out,  I  shall  state  briefly 
my  own  conclusions,  or  rather  what  seem  to  me  to  be  the  probable 
facts. 


Fracture  of  the  neck  of  the 
femur.     (Fergusson.) 


Signs  of  a  fracture  within  the 

CAPSULE. 

Produced  often  by  slight  violence. 
A  fall  upon  the  foot  or  knee,  or  a  trip 
upon  the  carpet,  &c. 

Generally  over  fifty  years  of  age. 
More  frequent  in  females. 

Pain,  tenderness,  and  swelling  less  and 
deeper. 


(The  two  following  measurements  to 
be  made  from  the  anterior  superior  spinous 
process  of  the  ilium  to  the  lower  extremity 
of  the  malleolus  exteruus  or  interuus. ) 

Shortening  at  first  less  than  in  extra- 
capsular fractures,  often  not  any. 

Shortening  after  a  few  days  or  weeks 
greater  than  in  extra-capsular  fractures. 
Sometimes  this  takes  place  suddenly,  as 
when  the  limb  is  moved,  or  the  patient 
steps  upon  it. 

Measuring  from  the  top  of  the  tro- 
chanter to  the  condyles  or  to  the  malleoli, 
the  femur  is  not  shortened. 


Signs  of  a  fracture  without  the 

CAPSULE. 

Produced  usually  by  greater  violence. 
A  fall  upon  the  trochanter  major. 

Often  under  fifty  years  of  age. 

Relative  frequency  in  males  or  females 
not  established. 

Pain,  swelling,  and  tenderness  greater 
and  more  superficial.  It  is  especially 
painful  to  press  upon  and  around  the 
trochanter. 


Shortening  at  first  greater,  almost 
always  some. 

Shortening  after  a  few  days  or  weeks 
less  than  in  intra-capsular  fractures. 
That  is,  the  amount  of  shortening  changes 
but  little,  if  at  all  ;  if  the  impaction  con- 
tinues, not  at  all ;  if  it  does  not  continue, 
it  may  shorten  more. 

Measuring  from  the  top  of  the  tro- 
chanter to  the  condyles  or  to  the  malleoli, 
the  femur  may  be  found  a  little  short- 
ened. 


380 


FRACTUEES    OF    THE    FEMUR. 


Signs  of  a  fracture  within  the 
CAPSULE  {continued). 

Trochanter  major  moves  upon  a  rela- 
tively longer  radius. 

If  the  patient  recovers  the  use  of  the 
limb,  not  restored  under  three  or  four 
months. 

No  enlargement  or  apparent  expansion 
of  the  trochanter  major,  after  recovery, 
from  deposit  of  bony  callus. 

Progressive  wasting  of  the  limb  for 
many  months  after  recovery. 

Excessive  halting,  accompanied  with 
a  peculiar  motion  of  the  pelvis,  such  as 
is  exhibited  in  persons  who  walk  with  an 
artificial  limb. 


Signs  op  a  fracture  without  the 
CAPSULE  {continued). 

Trochanter  major  moves  upon  a  rela- 
tively shorter  radius. 

If  the  patient  recovers  the  use  of  the 
limb,  restored  in  six  or  eight  weeks. 

Enlargement  or  irregular  expansion  of 
trochanter,  which  may  be  felt  sometimes 
distinctly  through  the  skin  and  muscles. 

The  limb  preserving  its  natural 
strength  and  size. 

Slight  halt,  motions  of  hip  natural. 


Prognosis. — In  attempting  to  establish  the  differential  diagnosis,  we 
have  necessarily  been  led  to  consider  most  of  the  essential  points  of 
prognosis.     Very  little,  therefore,  remains  to  be  said  upon  this  subject. 

Union  generally  occurs  as  rapidly  in  this  fracture  as  in  fractures 
of  the  shaft,  and  ))erhaps  even  sometimes  more  promptly,  owing  to 
the  existence  of  impaction. 

But  whether  it  occurs  promptly  or  slowly,  or,  indeed,  if  it  does  not 
occur  at  all,  a  remarkable  deposit  of  ossific  matter  almost  invariably 
takes  place  along  the  inter-trochanteric  lines,  where  the  bone  has 
separated  from  the  shaft,  and  also,  not  unfrequently,  along  the  lines  of 
the  other  fractures  of  the  trochanter. 

Fill-.  139. 


Fi^.  128. 


Extra-caps>ular  fracture.     (Ericlisen.) 


Extra-capsular  fracture.     (U.  Smith.) 


This  deposit  is  no  less  remarkable  for  its  abundance  than  for  its 
irregularity,  long  spines  of  bone  often  rising  up  toward  the  pelvis  and 
forming  a  kind  of  nobby  or  spiculated  crown,  within  which  the 
acetabular  fragment  reposes.  In  a  few  instances  these  osteophites 
have  reached  even  to  the  bones  of  the  pelvis,  and  formed  powerful 


NECK,  WITHOUT  THE  CAPSULE, 


381 


Fis.  130. 


abutments  which  seemed  to  prevent  any  farther  dispLacement  of  the 
limb  in  this  direction,  and,  by  some  writers,  they  have  been  supposed 
thus  to  fulfil  a  positive  design.  A  sufficient  explanation  of  their  ex- 
istence, however,  we  think,  can  be  found  in  the  fact  that  they  proceed 
entirely  from  the  trochanteric  fragments,  whose  extensive  comminu- 
tion and  great  vascularity  would  naturally  lead  to  such  results.  The 
same,  but  in  a  less  degree,  has  already  been  noticed  as  occurring  in 
impacted  fractures  at  the  anatomical  neck  of  the  humerus,  where  cer- 
tainly such  bony  abutments  could  not  serve  any  useful  purpose. 

Treatment. — The  same  principles  of  treatment  are  applicable  here  as 
in  fractures  of  the  neck  within  the  capsule;  by  which  I  mean  to  say  that, 
as  in  all  of  those  examples  of  fracture  within  the  capsule  where  the  rela- 
tion of  the  fragments  is  such  as  to  warrant  a  hope  that  a  bony  union  may 
be  consummated,  namely,  where  the  frag- 
ments are  not  displaced  or  are  impacted, 
the  straight  position,  with  only  moderate 
extension,  constitutes  the  most  rational 
mode  of  treatment;  so  also  in  this  fracture, 
whenever  the  fragments  are  impacted  and 
remain  impacted,  the  straight  position,  with 
moderate  extension,  employed  only  as  a 
means  of  retention,  but  not  so  as  to  over- 
come impaction,  is  the  most  suitable.  It 
is  only  by  employing  this  plan  of  treat- 
ment, which  no  one  has  yet  shown  to  be 
inapplicable  to  either  of  these  two  varie- 
ties of  accidents — I  do  not  speak  of  the 
opinions  which  men  may  have  entertained, 
but  of  the  practical  testimony — it  is  only, 
I  say,  by  employing  this  uniform  plan  of 
treatment  in  both  cases,  that  those  serious  misfortunes  to  tjje  patient 
can  be  avoided  which  would  necessarily  continue  to  occur  if  Sir  Ast- 
ley  Cooper's  advice  were  followed,  namely,  to  allow  the  patient  in  the 
one  case  to  dispense  with  splints  wholly,  and  to  get  upon  his  crutches 
as  soon  as  the  condition  of  his  limb  and  of  his  body  will  permit,  when 
it  is  certain  that  in  the  other  case  some  retentive  apparatus  is  gene- 
rally necessary.  This  conclusion  is  based  upon  the  admitted  difficulty 
of  diagnosis.  If,  as  is  well  understood,  the  diagnosis  between  these 
two  varieties  of  fracture  is  often  impossible  during  the  life  of  the  pa- 
tient, then  how  shall  we  know  in  any  given  case  which  of  the  two 
plans  to  adopt.  If  we  act  upon  the  supposition  that  it  is  within  the 
capsule,  adopting  Sir  Astley  Cooper's  method,  and  it  proves  to  have 
been  a  fracture  without  the  capsule,  we  have,  I  fear,  done  irreparable 
injury  to  our  patient.  It  is  precisely  here  that  this  distinguished  sur- 
geon committed  his  great  error;  not  in  denying  that  certain  specimens 
were  fractures  of  the  neck  of  the  femur  within  the  capsule  united  by 
bone,  nor  in  constantly  urging  upon  his  contemporaries  the  improba- 
bility of  such  an  event,  but  in  that,  while  he  admitted  its  possibility, 
he  chose  to  recommend  a  plan  of  treatment  which  was  unlikely  to 
insure  such  a  union,  and  which,  in  the  uncertainty  if  not  impossibility 


Extra-capsulai'  fi'acture. 


382 


FRACTURES    OF    THE    FEMUR. 


of  diagnosis,  was  liable,  upon  his  supposed  authority,  to  be  adopted 
in  many  cases  of  extra-capsular  fractures. 

Again,  if  the  fracture  be  extra-capsular  and  not  impacted,  or  the 
impaction  has  been,  for  any  cause,  overcome;  or,  if  the  fracture  be 
intra-capsular  and  not  impacted,  or  if  the  capsule  is  lacerated  and  the 
fragments  are  in  consequence  displaced;  then  again  no  injury  need 
result  from  the  treatment,  if  we  adopt  the  straight  position  with  mode- 
rate extension,  such  as  may  be  obtained  from  the  use  of  my  own  ap- 
paratus, or  Gibson's,  or  Miller's.  That  it  is  not  impacted  we  may  know 
often,  or  generally,  by  the  amount  of  displacement,  although  we  may 
not  easily  decide  whether  the  fracture  is  within  or  without  the  cap- 
sule. Now,  the  amount  of  shortening  will  determine  properly  enough 
the  amount  of  extension  to  be  employed.  In  either  case,  however, 
we  shall  not  employ  as  much  extension  as  in  fractures  of  the  shaft; 
and  while  in  the  one  case  we  shall  only  gain  a  shorter  and  firmer 
ligamentous  union,  in  the  other  we  shall  insure  a  better  and  more 
speedy  bony  union. 

If  any  surgeon,  acting  upon  the  suggestions  here  made,  shall  con- 
fine a  feeble  or  an  aged  person  in  the  horizontal  posture,  with  or  with- 


Fig.  131. 


Miller's  splint  for  extracapsular  fractures.     (From  Miller 


out  a  straight  splint,  until  the  powers  of  nature  have  become  exhausted, 
and  death  ensues,  as  our  readers  have  already  been  admonished  may 
happen,  we  are  not  to  be  held  responsible  for  his  want  of  judgment  or 
of  skill.  We  have  advised  this  plan  of  treatment  only  for  so  long  a 
period  as  the  condition  of  the  patient  renders  it  entirely  safe.  No 
doubt,  then,  in  a  large  number  of  cases  it  will  have  to  be  abandoned 
very  early,  and  in  not  an  inconsiderable  proportion  all  constraint  will 
be  plainly  inadmissible  from  the  heg inning ;  and  it  is  for  such  ex- 
amples that  the  treatment  recommended  by  Sir  Astley  Cooper  for  all 
intra-capsular  fractures  ought  to  be  reserved. 

(c.)  Fractures  of  the  Neck  partly  loithin  and  i^artly  icithout  the  Capsule. 

It  is  scarcely  necessaryto  say  that  the  line  of  fracture  through  the 
neck  of  the  femur  may  be  such,  that  it  shall  be  in  part  within  and  in 
part  without  the  capsule  ;  and  such  fractures  will  be  even  more  diffi- 
cult to  diagnosticate  than  either  of  those  forms  of  which  we  have  just 
spoken.  The  symptoms  will  be  mainly,  however,  those  which  cha- 
racterize fractures  within  the  capsule,  while  the  treatment  ought  to  be 


BASE    OF    THE    TEOCHANTER    MAJOR.  383 

such  as  we  would  adopt  in  those  fractures  which  are  wholly  without 
the  capsule.  The  chances  for  bony  union  are  increased  in  proportion 
as  the  line  of  separation  extends  outside  of  the  capsule,  and  we  ought 
to  be  diligent  in  our  efforts,  if  we  have  made  ourselves  certain  that 
the  fracture  is  partly  extra-capsular,  to  secure  a  good  bony  union  ;  a 
result  which  experience  has  shown  may  be  reasonably  anticipated. 

The  necessity  for  some  extension,  and  of  firm  retentive  apparatus 
in  this  form  of  fracture,  furnishes  another  argument  in  favor  of  the 
employment  of  the  same  means  in  fractures  wholly  within  the  capsule. 
We  shall  thus  avoid  the  mischief  which  might  arise  from  mistaking  a 
fracture  of  the  character  of  which  we  are  now  speaking,  for  a  fracture 
wholly  within  the  capsule. 

§  2.  Fracture  through  the  Trochanter  Major  and  Base  of  the 
Neck  op  the  Femur. 

This  fracture,  which  Sir  Astley  Cooper  calls  a  fracture  of  the  "femur 
through  the  trochanter  major,"^  passes  obliquely  upwards  and  outwards 
from  the  lower  portion  of  the  neck,  but  instead  of  traversing  the  neck 
completely,  it  penetrates  the  base  of  the  trochanter  major ;  the  line  of 
fracture  being  such  as  to  separate  the  femur  into  two  fragments,  one 
of  which  is  composed  of  the  head,  neck,  and  trochanter  major,  and  the 
other  of  the  shaft  with  the  remaining  portions  of  the  femur. 

The  following  two  examples  are  all  in  relation  to  which  we  possess 
any  positive  information,  or  in  which  the  diagnosis  has  been  con- 
firmed by  an  autopsy.    The  first  is  thus  related  by  Sir  Astley  Cooper. 

"  The  first  case  of  this  kind  I  ever  saw  was  in  St.  Thomas's  PIos- 
pital,  about  the  year  1786.  It  was  supposed  to  be  a  fracture  of  the 
neck  of  the  thigh-bone  within  the  capsule,  and  the  limb  was  extended 
over  a  pillow  rolled  under  the  knee,  with  splints  on  each  side  of  the 
limb,  by  Mr.  Cline's  direction.  An  ossific  union  succeeded,  with 
scarcely  any  deformity,  excepting  that  the  foot  was  somewhat  everted 
and  the  man  walked  extremely  well.  When  he  was  to  be  discharged 
from  the  hospital,  a  fever  attacked  him,  of  which  he  died;  and  upon 
dissection,  the  fracture  was  found  through  the  trochanter  major,  and 
the  bone  was  united  with  very  little  deformity,  so  that  his  limb  would 
have  been  equally  useful  as  before."^ 

The  second  example  is  reported  by  Mr.  Stanley. 

"A  woman,  in  her  sixtieth  year,  fell  in  the  street  and  injured  her 
right  hip.  On  examination,  the  limb  was  found  slightly  everted,  and 
shortened  to  the  extent  of  three-quarters  of  an  inch,  but  movable  in 
every  direction.  The  extremity  of  the  shaft  of  the  femur  was  in  its 
natural  situation ;  but  behind  the  femur,  and  at  a  little  distance  from 
it,  a  bony  prominence  was  discovered,  resting  upon  the  ilium,  toward 
the  great  sciatic  notch,  strongly  resembling  the  head  of  the  femur. 
Various  opinions  were  entertained  as  to  the  nature  of  the  injury,  some 
believing  it  to  be  dislocation,  and  others  a  fracture.  After  a  confine- 
meut  of  several  months  to  her  bed,  the  woman  was  sufficiently  re- 

1  Sir  Astley  Cooper,  op.  cit.,  p.  183.  2  Qp.  eit.,  p.  184. 


884         •  FRACTUKES    OF    THE    FEMUR. 

covered  to  walk  with  the  assistance  of  a  crutch,  and  in  this  state  she 
continued  till  her  death,  which  took  place  about  three  years  after  the 
accident,  during  the  whole  of  which  period  I  had  watched  the  pro- 
gress of  the  case.  Having  obtained  permission  to  examine  the  seat  of 
the  injury,  I  ascertained  that  there  had  been  a  fracture  extending 
obliquely  through  the  trochanter  major,  and  through  the  basis  of  the 
neck  into  the  shaft  of  the  femur,  and  that  the  prominence  which  had 
been  mistaken  for  the  head  of  the  bone  was  occasioned  by  the  posterior 
and  larger  portion  of  the  trochanter  drawn  backwards  toward  the 
ischiatic  notch.'" 

Sir  Astley  relates  three  other  examples  in  which  he  believes  the 
fractures  to  have  been  of  the  character  above  described  ;  and  he  details 
the  peculiar  plans  of  treatment  which,  in  each  case,  he  saw  fit  to  recom- 
mend. I  can  see  no  reason,  however,  why  the  treatment  need  differ 
from  that  which  has  already  been  recommended  for  fractures  of  the 
neck,  since  the  indications  are  nearly  identical  in  all  of  these  cases ; 
namely,  moderate  extension,  and  steady  support  of  the  limb  in  its 
natural  position. 

§  3.  Fracture  of  the  Epiphysis  of  the  Trochanter  Major. 

So  far  as  I  know,  the  only  well-authenticated  example  of  this  acci- 
dent is  the  one  reported  by  Mr,  Key  to  Sir  Astley  Cooper,^  The  sub- 
ject of  this  case  was  a  girl,  aged  about  sixteen  years,  who  fell,  March 
15,  1822,  upon  the  side-walk,  and  struck  her  trochanter  violently 
against  the  curb-stone.  She  arose,  and,  without  much  pain  or  difficulty, 
walked  home.  On  the  20th  she  Avas  received  into  Guy's  Hospital,  and 
the  limb  was  examined  by  Mr.  Key.  The  right  leg,  which  was  the 
one  injured,  was  considerably  everted,  and  appeared  to  be  about  half 
an  inch  longer  than  the  sound  limb.  It  could  be  moved  in  all 
directions,  but  abduction  gave  her  considerable  pain.  She  had  perfect 
command  over  all  the  muscles,  except  the  rotators  inwards.  No 
crepitus  could  be  detected.  Four  days  after  admission  she  died,  having 
succumbed  to  the  irritative  fever  which  followed  the  injury. 

The  autopsy  disclosed  a  fracture  through  the  base  of  the  trochanter 
major,  but  without  laceration  of  the  tendinous  expansions  which  cover 
the  outside  of  this  process,  so  that  no  displacement  of  the  epiphysis 
had  occurred,  nor  could  it  be  moved,  except  to  a  small  extent  upwards 
and  downwards.  A  considerable  collection  of  pus  was  found,  also, 
below  and  in  front  of  the  trochanter. 

The  absence  of  displacement  in  the  fragment,  with  its  peculiar  and 
limited  motion,  sufficiently  explained  why  the  fracture  could  not  be 
detected  during  life. 

In  the  eighth  volume  of  the  Transactions  of  the  Medical  and  Physical 
Society  of  Calcutta  (1835),  J,  Clarke,  Esq.,  reports  a  case  of  comminuted 
fracture  of  the  trochanter  major,  which  has  been  mentioned  by  Mal- 
gaigne  as  an  example  of  simple  fracture  of  the  trochanter;  but,  after 

'  Stanley,  Med.-Cbir.  Trans.,  vol.  xiii. 

2  Sir  Astley  Cooper  on  Dislocations  and  Fractures,  etc.,  Araer.  ed.,  1851,  p.  193. 


BASE  OF  THE  TROCHANTER  MAJOR. 


885 


reading  the  case  carefully,  I  cannot  avoid  the  conclusion  that  it  was 
an  example  of  fracture  of  the  neck  without  the  capsule,  accompanied 
with  impaction  and  extensive  comminution.  "  Extravasation,"  says 
Mr.  Clarke,  "was  discovered  within  the  capsular  ligament  and  around 
the  trochanter  major;  and,  on  clearing  away  the  muscles,  the  trochan- 
ter was  found  crushed  and  shattered,  several  pieces  entirely  detached, 
and  fissures  extending  deeply  into  the  shaft  of  the  bone."^ 

I  shall  venture  to  express  the  same  opinion  in  relation  to  the  case 
reported  by  Bransby  Cooper.'^  The  diagnosis  was  not  confirmed  by 
an  autopsy,  and  the  testimony  drawn  from  Mr.  Cooper's  account  of 
the  case  is  far  from  being,  to  my  mind,  conclusive.  It  may,  indeed, 
have  been  a  simple  fracture  of  the  epiphysis  ;  but  there  is  nothing  in 
the  narrative  to  render  it  improbable  that  there  existed  also  an  im- 
pacted extra-capsular  fracture  of  the  neck. 

I  have  also  myself  reported  one  example  of  this  fracture  as  having 
come  under  my  own  observation,^  but  of  which  I  wish  now  to  speak 
somewhat  less  confidently.  The  patient,  James  Redwick,  a  travelling 
showman,  cet.  23,  fell,  in  August,  1848,  from  a  high  wagon,  striking 
upon  his  left  hip.  When  he  got  upon  his  feet,  he  found  himself  un- 
able to  walk,  and  was  carried  to  his  room.  Dr.  Wilcox,  of  Buffalo, 
was  called  to  see  him,  and  applied  a  long  straight  splint.  Fourteen 
days  after  the  accident  I  saw  the  patient  with  Dr.  Wilcox.  The  thigh 
was  not  appreciably  shortened,  nor  was  there  either  eversion  or  inver- 
sion ;  but  the  epiphysis  of  the  trochanter  major  was  carried  upwards 
toward  the  crest  of  the  ilium  half  an  inch,  and  slightly  sent  in.  No 
crepitus  could  be  detected.  The  splint  was  continued  five  weeks  ;  and 
about  a  month  after,  I  found  the  fragment  in  the  same  place,  but  he 
was  able  to  walk  with  only  a  slight  halt. 

I  think  this  also  may  have  been  an  extra-capsular  impacted  fracture. 

Fiff. 133. 


Sir  Astley  Cooper's  mode  of  treating  fractures  of  the  trochanter  major.     (From  A.  Cooper.) 

With  the  small  amount  of  positive  information  which  we  possess  in 
relation  to  this  fracture,  we  might  venture  a  few  conjectures  as  to  what 
would  constitute  its  symptoms,  or  as  to  the  probable  results  and  the 
most  suitable  treatment ;  but  we  prefer  to  occupy  ourselves  with  a 

1  Clarke,  Amer.  Journ.  Med.  Sci.,  Nov.  1836,  vol.  ix.  p.  181. 

2  B.  Cooper,  A.  Cooper  on  Dislocations,  &c..  op.  cit.,  p.  103. 

'  Hamilton,  Trans.  Amer.  Med.  Assoc,  op.  cit.,  vol.  x.  p.  2o4. 


386 


FRACTUEES    OF    THE    FEMUR. 


simple  statement  of  tlie  facts,  so  far  as  they  are  known,  leaving  all 
mere  speculative  inferences  to  those  who  choose  to  make  them. 


§  4.  Fractures  of  the  Shaft  of  the  Femur. 

Etiology. — Unless  the  fracture  has  taken  place  just  above  the  con- 
dyles, or  immediately  below  the  trochanter  minor,  in  a  very  large 
proportion  of  cases  it  has  been  produced  by  a  direct  blow,  such  as 
the  passage  of  a  loaded  vehicle  across  the  thigh,  or  the  fall  of  a  piece 
of  timber  directly  upon  it.  An  analysis  of  twenty-one  cases,  taken 
indiscriminately,  presents  three  fractures  immediately  above  the  con- 
dyles, and  these  were  all  produced  by  falls  upon  the  feet ;  but  of  the 
remaining  eighteen,  all  of  which  occurred  higher  in  the  limb,  only 
two  were  the  result  of  falls  upon  the  feet  or  of  indirect  blows,  and 
one  of  these  was  a  fracture  just  below  the  trochanter  minor. 

Pathology. — It  has  already  been  remarked  that  this  bone  is  most 
frequently  broken  in  its  middle  third,  and  usually  at  a  point  some- 
what above  the  middle  of  the  shaft.  I  have  made  the  same  observa- 
tion in  an  examination  of  specimens  belonging  to  Dr.  Miitter.  In 
his  cabinet,  of  twenty-four  fractures  of  the  shaft,  three  belonged  to  the 
upper  third,  two  to  the  lower,  and  nineteen  to  the  middle  third. 

In  the  adult,  these  fractures  are,  with  only  an  exceedingly  rare  ex- 
ception, oblique ;  and  the  obliquity  is  generally  greater  than  in  the 
case  of  other  T3ones.  This  fact,  which  it  is  very  difficult  to  deter- 
mine, in  most  cases,  upon  the  living  subject,  I  have  established  by  a 
considerable  number  of  observations  made  upon  cabinet  specimens. 
A  transverse  fracture  is  found  only  twice  in  Dr.  Mussey's  collection, 
containing  thirty  examples  of  fracture  of  the  shaft;  and  in  Dr.  Miit- 
ter's  collection,  specimen  B  71  is  an  adult  femur,  broken  nearly  trans- 
versely through  its  middle  third;  and  it  is  united  with  a  shortening 
of  about  one  inch.  Indeed,  it  is  more  common  to  find  a  transverse 
fracture  in  the  middle  third  than  at  any  other  point  of  the  bone;  but 
in  the  upper  third  the  obliquity  is  extreme  and  almost  constant. 

At  whatever  point  of  the  shaft  the  bone  is  broken,  the  degree  of 
obliquity  is  generally  such  that  the  fragments  cannot  support  each 
other  when  placed  in  apposition ;  unless  indeed  the  fracture  is  near 
the  condyles,  where  the  greater  breadth  of  the  bone  creates  an  addi- 
tional support ;  but  even  here  the  cabinet  specimens  still  present  a 
striking  obliquity,  with  more  or  less  overlapping.  I  believe  that  in 
each  of  the  three  specimens  of  fracture  at  this  point  found  in  the 
collection  belonging  to  the  Albany  Medical  College,  the  obliquity  is 
such  that  the  fragments  were  not  supported,  and  an  overlapping  has 
taken  place.  In  specimen  719  the  fracture  extends  into  the  joint ; 
and  although  it  is  united  by  bone,  a  shortening  of  about  one  inch  has 
occurred. 

In  the  case  of  children,  and  especially  of  infants,  the  rule  is  reversed ; 
the  bone  is  either  broken  transversely  or  nearly  transversely,  or  it  is 
serrated  or  denticulated,  so  that  complete  lateral  displacement  is  much 
less  frequent. 

The  same  remark  is  probably  true  of  some  fractures  occurring  in 


FEACTURES    OF    THE    SHAFT    OF    THE    FEMUR. 


387 


Fiir.  133. 


Fracture  at  base  of  coudyles. 


extreme  old  age;  but  as  the  shaft  of  the  femur  is  not  often  broken  in 
very  old  persons,  owing  to  the  readiness  with  which  the  neck  yields 
to  violence,  I  have  not  had  an  opportunity  to  verify  this  opinion. 

The  direction  of  the  obliquity  varies  exceedingly,  especially  in  the 
middle  and  upper  thirds ;  in  the  middle  third,  however,  it  is  generally 
downwards  and  inwards;  but  in  the  lower 
third  its  direction  is,  with  only  rare  excep- 
tions, downwards  and  forwards,  and  the  su- 
perior fragment  is  found  lying  in  front  of 
the  inferior. 

In  one  instance  I  have  found  both  femurs 
broken  at  the  same  point  and  in  the  same 
manner.  Mr.  L.  Brittin,  aged  about  fifty-five 
years,  while  employed  upon  a  building,  fell 
from  a  fourth  story  window  upon  the  stone 
pavement  below,  striking  upon  his  feet.  In 
addition  to  several  other  fractures,  I  found 
both  femurs  broken  obliquely  downwards 
and  forwards,  just  above  the  condyles.  Very 
little  inflammation  ensued,  and  although  it 
was  found  impossible  to  employ  extension, 
union  occurred  readily,  and  with  only  a  mode- 
rate overlapping.  In  the  left  limb,  however, 
the  upper  fragment  pressed  down  sufficiently 
to  interfere  somewhat  with  the  patella,  and 

the  patient  was  unable,  after  several  months,  to  straighten  the  knee 
completely.     The  motions  of  the  right  knee  were  unimpaired. 

I  have  only  once  met  with  a  fracture  at  this  point  in  which  the  line 
of  separation  was  downwards  and  backwards.  As  the  case  presents 
several  points  of  interest,  it  will  be  proper  to  narrate  the  facts  some- 
what at  length. 

George  Taylor  Aiken,  of  Lockport,  N.  Y.,  a3t.  7.  May  18,  1854,  in 
jumping  down  a  bank  of  about  three  feet  in  height,  he  broke  the  right 
thigh  obliquely,  just  above  the  knee-joint.  Direction  of  the  fracture 
obliquel}''  downwards  and  backwards. 

Dr.  Gr.,  an  accomplished  surgeon,  residing  in  Lockport,  was  called. 
The  limb  was  not  then  much  swollen.  He  applied  side  splints,  rollers, 
&c.,  carefully,  and  then  laid  the  limb  over  a  double-inclined  plane. 
The  knee  was  elevated  about  six  or  eight  inches.  Before  applying 
the  splints,  suitable  extension  had  been  made,  and  after  completing 
the  dressings,  the  two  limbs  seemed  to  be  of  the  same  length. 

On  the  second  or  third  day.  Dr.  G.  noticed  that  the  toes  looked 
unnaturally  white,  and  were  cold. 

Counsel  was  now  called  at  the  request  of  Dr.  G.,  when  it  was  de- 
termined to  abandon  all  dressings,  and  direct  their  eftbrts  solely  to 
saving  the  limb. 

The  result  was  that  slowly  a  considerable  portion  of  his  foot  died 
and  sloughed  away,  leaving  only  the  tarsal  bones  The  fracture 
united,  but  with  considerable  overlapping  and  deformity. 

Feb.  26;  1856,  the  boy  was  brought  to  me  by  his  father.     On  ex- 


388  FKACTUEES    OF    THE    FEMUR. 

amining  the  fracture,  I  noticed  that  the  anterior  line  of  the  femur 
seemed  nearly  straight,  and  this  appearance  was  owing  in  some  de- 
gree to  the  muscles  which  covered  and  concealed  the  bone,  and  in 
some  degree,  also,  to  the  manner  in  which  the  fragments  rested  upon 
each  other;  the  pointed  superior  end  of  the  lower  fragment  resting 
snugly  upon  the  front  of  the  upper  fragment,  so  that  no  abrupt  angle 
existed  in  front.  On  the  back  of  the  limb,  however,  the  lower  end 
of  the  upper  fragment,  quite  sharp,  projected  freely  downwards  and 
backwards  into  the  popliteal  space,  so  that  its  extreme  point  was 
only  about  half  an  inch  above  the  line  of  the  articulation.  The  limb 
had  shortened  one  inch,  and  this  enabled  us  to  determine  accurately 
that  the  lower  point  or  the  comtnencement  of  the  fracture  was  one 
inch  and  a  half  above  the  articulation,  while  the  point  where  the  line 
of  fracture  terminated  in  front  was  probably  quite  three  inches  and  a 
half  above  the  joint. 

The  motions  of  the  knee-joint  were  pretty  free.  The  leg  was  ex- 
tremely wasted,  and  the  anterior  half  of  the  foot  having  sloughed  off, 
the  sores  had  now  completely  healed  over.  He  was  able  to  walk 
tolerably  well  without  either  crutch  or  cane. 

Subsequently,  Dr.  G.  found  it  necessary  to  sue  the  father  of  the 
child  for  the  amount  of  his  services,  when  Mr.  Aikin  put  in  a  plea  of 
malpractice,  and  that  consequently  the  services  were  without  value. 

The  case  was  tried  in  the  March  term  of  the  Niagara  circuit  of 
1856,  at  Lockport,  N.  Y.,  the  Hon.  Benj.  F.  Greene  presiding. 

On  the  part  of  the  defence,  it  was  claimed  that  the  death  of  the  foot 
was  in  consequence  of  the  bandages  being  too  tight.  They  failed, 
however,  to  show  that  they  were  extraordinarily  or  unduly  tight. 
"While  on  the  part  of  Dr.  G.,  the  prosecutor,  it  was  shown  that  the 
death  of  the  toes  was  preceded  by  a  total  loss  of  color,  and  that  it  was 
not  accompanied  with  either  venous  or  arterial  congestion.  The  medi- 
cal gentlemen  examined  as  witnesses  declared  that  this  circumstance 
furnished  the  most  positive  evidence  which  could  be  desired  that  the 
death  of  the  toes  was  not  due  to  the  tightness  of  the  bandages,  but  that 
its  cause  must  be  looked  for  in  an  arrest  of  the  arterial  or  nervous 
currents  supplying  the  limb,  or  in  both.  They  believed,  also,  that 
the  projection  of  the  superior  fragment  into  the  popliteal  space  was 
sufficient  to  cause  this  arrest.  They  also  believed  that  overlapping 
and  consequent  projection  could  not  have  been  prevented  in  this  case, 
and  that,  therefore,  the  treatment  was  not  responsible  for  this  unfor- 
tunate result:  indeed,  they  regarded  the  treatment  as  correct,  and  the 
result  as  a  triumph  of  skill,  in  that  any  portion  of  the  limb  was  saved ; 
the  leg  and  foot  now  remaining  being  far  more  useful  than  any  artifi- 
cial leg  and  foot  could  be. 

The  Hon.  Judge,  in  a  speech  remarkable  for  its  clearness  and  libe- 
rality sought  to  impress  upon  the  jury  the  value  of  the  medical  testi- 
mony. The  jury  returned  a  verdict  for  Dr.  G.,  allowing  the  amount 
of  his  claim  for  services,  with  the  costs  of  suit. 

Specimen  121,  in  Dr.  March's  collection  at  Albany,  presents  a 
similar  disposition  of  the  fragments.  The  fracture  is  oblique,  from 
above  downwards  and  backwards,  and  the  upper  portion  lies  behind 


FRACTURES    OF    TPIE    SHAFT    OF    THE    FEMUR.  389 

the  lower.  It  is  firmly  united  by  bone,  but  with  an  overlapping  of 
from  two  and  a  half  to  three  inches.  The  young  gentleman  who 
showed  me  the  specimen  remarked  that  it  had  been  found  impossible, 
owing  to  an  ulcer  upon  the  heel,  and  to  other  causes,  to  employ  in  the 
treatment  any  degree  of  extension. 

These  two  are  the  only  examples  which  have  come  under  my  ob- 
servation in  which  a  fracture  at  this  point  has  taken  this  direction. 

Sir  Astley  Cooper  does  not  seem  to  have  recognized  this  form  of 
fracture  and  displacement.  Amesbury  has,  however,  recorded  one 
case,  which  came  under  his  own  observation,  where,  although  the 
bloodvessels  and  nerves  escaped,  the  bone  projected  through  the  skin 
in  the  ham,  and  finally  exfoliated.^  And  he  thinks  the  point  of  bone 
may  sometimes  so  penetrate  the  artery  and  injure  the  nerves  as  to 
render  amputation  necessary,  in  order  to  save  the  life  of  the  patient. 

M.  Coural  also  has  related  a  case  in  which  an  epiphysary  disjunc- 
tion, occurring  in  a  child  twelve  years  old,  was  attended  with  a  dis- 
placement of  the  upper  fragment  backwards,  and  amputation  became 
necessary.^     I  shall  refer  to  this  case  again. 

I  know  of  no  other  cases  of  this  rare  accident  which  have  been  re- 
ported. Lonsdale  refers  to  it  as  "the  rarest  direction  for  a  fracture  to 
take ;"  and  thinks  that  in  case  of  its  occurrence,  the  vessels  in  the 
popliteal  space  will  stand  a  chance  of  being  wounded  ;  but  he  mentions 
no  example.  The  popliteal  artery  hugs  the  bone  so  closely  at  this 
point,  that  a  displacement  of  the  upper  fragment  in  a  direction  down- 
wards and  backwards  must  always  greatly  endanger  its  integrity. 
Indeed,  it  is  here  that  the  artery  and  vein  are  in  the  closest  contact 
with  each  other,  and  with  the  bone;  an  anatomical  fact  which  has 
been  used  by  Richerand  and  others  to  explain  the  greater  frequency 
of  aneurisms  in  the  ham. 

The  direction  of  the  displacement,  however,  in  fractures  of  the  shaft 
of  the  femur,  does  not  always  depend  upon  the  direction  of  the  line  of 
fracture.  In  fractures  of  the  upper  third,  whatever  may  be  the  direc- 
tion of  the  line  of  fracture,  the  lower  end  of  the  upper  fragment  in- 
clines forwards  and  outwards,  and  the  upper  end  of  the  lower  frag- 
ment inwards;  unless,  indeed,  this  inclination  is  controlled  by  actual 
entanglement  of  the  broken  ends  with  each  other. 

In  the  middle  third  the  I'ragments  also  generally  take  the  same  rela- 
tive position,  whatever  may  be  the  direction  of  the  fracture ;  but  when 
the  fracture  takes  place  at  or  near  the  condyles,  where  the  diameter 
of  the  bone  is  much  greater,  the  direction  of  the  obliquity  determines 
pretty  uniformly  the  direction  of  the  displacement. 

Si/'/nptoni,s. — The  symptoms  which  characterize  a  fracture  of  the 
shaft  of  the  femur  are  those  which  are  common  to  all  fractures, 
namely,  mobility,  crepitus,  displacement  of  the  fragments,  pain,  and 
swelling,  to  which  are  added  generally  a  shortening  of  the  limb,  with 
eversion  of  the  foot  and  leg. 

Owing  to  the  great  amount  of  muscle  covering  the  thigh,  and  some- 

'  Remarks  on  Fractures,  &c.,  by  Joseph  Amesbury,  vol.  i.  p.  293.    London,  1831. 
2  Archiv.  Gen.  de  Med.,  tom.  ix.  p.  2G7. 


390  FRACTURES  OF  THE  FEMUR, 

times  to  the  swelling  which  immediately  follows  the  injury,  it  is  often 
very  diffiicult  to  determine  at  what  precise  point  the  fracture  has 
occurred,  and  still  more  difficult  to  say  whether  the  fracture  is  oblique 
or  transverse ;  indeed,  this  latter  question  is  sometimes  decided  ap- 
proximately by  a  reference  to  the  age  of  the  patient  rather  than  by 
the  examination  of  the  limb. 

The  immediate  shortening  varies  from  half  an  inch  to  an  inch  and 
a  half,  or  even  more ;  and  it  will  average  about  one  inch  in  the  case 
of  healthy  adults. 

Prognosis. — Whatever  may  have  been  the  general  opinion  of  ex- 
perienced surgeons  as  to  the  question  of  shortening  in  other  fractures, 
very  few  certainly  have  ever  claimed  that  in  fractures  of  the  femur  a 
complete  restoration  of  the  bone  to  its  original  length  was  generally 
to  be  expected.  There  seem,  however,  to  have  existed  only  certain 
vague  and  indefinite  notions  as  to  the  proportion  and  amount  of  this 
shortening,  and  which  have  had  for  their  basis  nothing  better  than  a 
few  imperfectly  analyzed  observations. 

Says  Scultetus  (quoting  first  from  Hippocrates):  "'For  the  bones  of 
the  thigh,  though  you  do  draw  them  out  by  force  of  extension,  cannot 
be  held  so  by  any  hands;  but  when  the  first  intention  slacks,  they  will 
run  together  again ;  for  here  the  thick  and  strong  flesh  are  above 
binding,  and  binding  cannot  keep  them  down.' — Hippocrates  defract. 
TVhich  Celsus  seems  to  confirm,  Lib.  8,  cap.  10,  where  he  writes  as 
follows  of  the  cure  of  legs  and  thighs :  '  For  we  must  not  be  ignorant 
that  if  the  thigh  be  broken,  that  it  will  be  made  shorter,  because  it 
never  returns  to  its  former  state.'  And  Avicenna,  Lib.  4:,  Fen.  5,  saith 
'  that  it  is  a  rare  thing  for  the  thigh  once  broken  to  be  perfectly  cured 
again.' 

"These  words  admonish  us,"  continues  Scultetus,  "that  we  should 
never  promise  a  perfect  cure  of  the  thigh ;  but  rather,  using  all  dili- 
gence, we  should  foretell  that  it  is  doubtful  that  the  patient  will  be  always 
lame;  but  when  this  shall  happen  from  the  nature  of  the  fracture,  or, 
which  most  frequently  falls  out,  from  the  impatience  of  the  sick  per- 
son, it  may  be  imputed  to  our  mistake,  and,  instead  of  a  reward,  bring 
us  disgrace."^ 

Says  Chelius  :  "  Fracture  of  the  thigh-bone  is  always  a  severe  acci- 
dent, as  the  broken  ends  are  retained  in  proper  contact  with  great 
difficulty.  The  cure  takes  place  most  commonly  with  deformity  and 
shortening  of  the  limb,  especially  in  oblique  fractures,  and  those  which 
occur  in  the  upper  and  lower  third  of  the  thigh-bone.  Compound 
fractures  are  so  much  more  difficult  to  treat."^ 

Says  John  Bell :  "  The  machine  is  not  yet  invented  by  which  a 
fractured  thigh-bone  can  be  perfectly  secured."  And  Benjamin  Bell 
declares  that  "  an  effectual  method  of  securing  oblique  fractures  in 
the  bones  of  the  extremities,  and  especially  of  the  thigh-bone,  is 
perhaps  one  of  the  greatest  desiderata  in  modern  surgery."     "  In  all 

'  The  Chirurgeon's  Store -house,  by  Johannes  Scultetus,  a  Famous  Physician 
and  Chirurgeouof  Ulme  in  Suevia.     Loudon,  1674. 

2  System  of  Surgery,  by  J.  M.  Chelius,  translated,  &c.,  by  South.  First  Amer. 
ed.,  vol.  i.  p.  627,  1847.     See  also  p.  635,  paragraph  679. 


FKACTUEES  OF  THE  SHAFT  OF  THE  FEMUR,     391 

ages,"  he  adds,  "the  difficulty  of  this  has  been  confessedly  great;  and 
frequent  lameness,  produced  by  shortened  limbs  arising  from  this 
cause,  evidently  shows  that  we  are  still  deficient  in  this  branch  of 
practice."^ 

Velpeau  saj^s  that  "after  fractures  of  the  femur  there  is  no  limp- 
ing unless  the  shortening  exceeds  three-quarters  of  an  inch;  and  the 
same  is  true  if  the  shortening  occurs  in  the  tibia."  The  reason  is,  tliat 
the  pelvis  inclines  toward  the  shorter  limb,  and  thus  compensates  for 
the  deficiency  in  length.  In  speaking  of  the  various  contrivances  for 
dressing  the  fractured  femur,  he  remarks  that  "  most  of  them  fail  to 
obviate  the  shortening,  and  produce  eschars,  anchylosis,  or  troublesome 
arrests  of  the  circulation.  This  is  the  price  that  is  usually  paid  for 
the  emploj'ment  of  these  complicated  machines,  and  a  shortening  of  a 
quarter  to  three-quarters  of  an  inch  is  not  avoided  after  all.  The 
simplest  apparatus  that  will  maintain  the  adjustment  of  the  fractured 
femur,  so  that  union  may  take  place  with  shortening  of  only  half  an 
inch,  is  the  best."^ 

Nelaton  holds  the  followino:  lang-uasje  : — 

"A  fracture  of  the  body  of  the  femur,  with  an  adult,  is  always  a 
grave  accident,  inasmuch  as  it  demands  so  long  a  confinement  to  the 
bed,  and  especially  on  account  of  the  shortening  of  the  limb,  which  it 
is  almost  impossible  wholly  to  prevent;  accordingly,  Boyer  recom- 
mends to  the  surgeon,  from  the  first  day,  to  announce  to  the  parents 
of  the  patient  the  possibility  of  this  accident.  With  infants,  on  the 
contrary,  it  is  almost  always  easy  to  avoid  the  shortening."^ 

While  Malgaigne  declares  his  opinion  on  this  subject  thus,  at 
length : — 

"  When  we  do  not  succeed  in  drawing  back  the  misplaeed  fragments, 
end  to  end,  so  that  they  may  oppose  themselves  to  the  action  of  the 
muscles,  it  is  impossible  to  preserve  to  the  member  its  normal  length, 
whatever  may  be  the  appareil  or  method  employed.  Surgeons  are 
not  sufficiently  agreed  upon  this  question. 

"At  a  period  quite  recent,  Desault  pretended  to  cure  all  fractures 
without  shortening,  and  his  journal  contains  several  examples.  In 
imitation  of  Desault,  various  practitioners  have  modified,  corrected, 
and  improved  the  apparatus  for  permanent  extension,  and  they  claim 
to  have  themselves  obtained  as  complete  success.  I  ought  then  to 
declare  here  in  the  most  positive  manner  that  I  have  never  obtained 
like  results,  either  in  the  use  of  m}^  own  apparatus,  or  with  that  of 
others,  nor  indeed  where,  in  pursuance  of  my  invitation,  several 
inventors  have  applied  their  apparatus  in  my  wards.  I  have  exam- 
ined, more  than  once,  persons  declared  cured  without  shortening,  and 
yet,  upon  measurement,  the  shortening  was  always  manifest.  The 
misfortune  of  all  those  who  believe  that  they  have  obtained  those 
miraculous  cures  is,  that  they  have  not  even  thought  of  instituting  a 

•  System  of  Surgery,  by  Benjamin  Bell,  vol.  vii.  p.  21.     Edinburgh,  ISOl. 

2  Peninsular  Journ.  of  Med.,  vol.  iii.  p.  384;  also  Memphis  Med.  Journ.,  vol.  iv. 
p.  254,  1856. 

3  Elemens  de  Pathologie  Cliirurgicale,  par  A.  Nelaton,  torn,  prem.,  p.  752.  Paris, 
1844. 


392  FRACTURES    OF    THE    FEMUR. 

comparative  measurement  of  the  two  limbs;  I  will  say  even  more, 
that  they  are  most  generally  ignorant  of  the  conditions  of  a  good  and 
faithful  measurement.  Sometimes,  also,  they  have  been  deceived  in 
another  way — in  falling  upon  fractures  which  were  not  displaced, 
especially  with  young  persons ;  and  they  have  believed  that  they  have 
cured  with  their  apparatus  a  shortening  which  had  never  existed.  In 
short,  when  the  fragments  are  not  displaced,  or  even  when  they  are 
brouo-ht  again  into  a  contact  maintained  by  their  reciprocal  denticu- 
lations,  it  is  easy  to  cure  the  fracture  of  the  femur  without  shorten- 
ino-;  aside  of  those  two  conditions,  the  thing  is  simply  impossible. 

"  Several  distinguished  surgeons  of  our  day  have  acknowledged  this 
impossibility,  and  have  renounced,  in  consequence,  permanent  exten- 
sion. They  allege,  moreover,  that  an  overriding  of  even  three  centi- 
metres is  of  little  importance,  and  occasions  no  limping.  I  cannot 
agree  with  this  opinion.  I  have  seen  persons  walk  very  well  with  a 
shortening  of  one  centimetre;  beyond  this  limit,  either  they  limp,  or 
they  have  lifted  the  heel  of  the  shoe,  or,  in  short,  the  limping  is  only 
concealed  by  a  lateral  deviation  of  the  spine.^  We  thus  are  made  to 
comprehend  how  a  fracture  with  overlapping  is  always  serious,  and 
how  cautious  we  ought  to  be  in  our  prognosis."^ 

That  the  foregoing  remarks  are  intended  by  the  author  to  be  equally 
applicable  to  other  fractures  of  the  shaft  of  the  femur  than  to  those  of 
the  middle  third,  is  made  evident  by  what  he  has  said  before,  when 
speaking  of  fractures  of  the  upper  third. 

"  The  prognosis  is  sufficiently  favorable  when  the  fragments  are 
denticulated  (engren^es);  when  they  ride,  on  the  contrary,  we  must 
look  for  a  shortening  as  almost  inevitable."^ 

Mr.  Holthouse  says*  that  in  1657  he  examined  all  the  fractured 
thighs  then  under  treatment  in  the  different  hospitals  in  London,  and 
in  the  case  of  adults  all  were  shortened  except  three,  and  he  thinks 
it  doubtful  whether  in  these  three  cases  his  examinations  were  of  any 
value.  In  thirty-five  examples  the  average  shortening  exceeded  one 
inch.     In  the  case  of  children  40  per  cent,  were  shortened. 

In  our  own  country  several  of  the  most  distinguished  surgeons  have 
testified  to  the  constant  difficulty,  if  not  impossibility,  of  curing  frac- 
tures of  this  bone  without  a  shortening.  In  a  suit  instituted  against 
a  suro-eon  in  New  York  city,  for  alleged  malpractice  in  the  treatment 
of  an  oblique,  comminuted,  and  otherwise  complicated  fracture  of  the 
femur  near  its  condyles,  Dr.  Mott  is  reported  to  have  testified  that 
"  more  or  less  shortening  of  the  limb  is  uniformly  the  result  after 
fractured  thigh,  even  in  the  most  favorable  circumstances."^ 

'  Dr.  Buck,  of  New  York,  thinks  that  with  a  shortening  of  one  inch,  or  even  one 
inch  and  a  half,  the  patient  may  have  "a  useful  limb,  with  little  or  no  halting  in 
his  gait."     N.  Y.  Journ.  of  Med.,  vol.  xvi.  p.  294. 

2  Traite  des  Fractures  et  des  Luxations,  par  J.  M.  Malgaigue,  torn,  prem.,  pp.  723, 
724.     Paris,  1847. 

3  Op.  cit.,  p.  718. 

i  Holthouse,  Holmes'  System  of  Surgery.     London,  1861,  vol.  ii.  p.  613. 

5  Boston  Med.  and  Surg.  Journ.,  vol.  xxxiv.  p.  450.  See  also  opinions  of  Drs. 
Reese.  Post,  Parker,  Cheeseman,  Wood,  &c.,  in  relation  to  the  prognosis  in  this 
particular  case. 


FRACTURES  OF  THE  SHAFT  OF  THE  FEMUR.     393 

In  a  very  interesting  communication  made  to  the  author  by  Jona- 
than Knight,  of  New  Haven,  late  President  of  the  American  Medical 
Association,  occurs  the  following  passage: — 

"I  have  seen  but  few  fractures  of  the  femur  in  the  adult,  unless  of 
the  most  simple  kind,  in  which  there  was  not  some  remaining  de- 
formity;  often  slight,  so  as  not  to  impair  the  usefulness  of  the  limb, 
and  in  others  considerable  and  apparently  unavoidable."  Dr.  Knight 
adds,  however  :  "  In  the  greater  proportion  of  the  fractures  in  children 
the  recovery  has  been  so  nearly  perfect  that  no  marked  deformity  or 
lameness  has  followed." 

Dr.  Detmold,  in  his  remarks  made  before  the  New  York  Academy 
of  Medicine,  at  its  meeting  in  March,  1855,  declared  his  belief  that  a 
shortening  of  the  femur  always  occurs  after  fracture,  and  that  "but 
one  inch  of  shortening  in  an  average  of  twenty  cases  is  a  good  result."^ 
Dr.  J.  Mason  Warren,  of  Boston,  writes  to  me  as  follows :  "As  you 
are  makinoj  observations  on  fractures,  I  would  state  that,  after  a  lona^ 
and  very  careful  observation,  I  have  never  yet  seen,  either  in  Boston 
or  elsewhere,  an  oblique  fracture  of  the  thigh,  in  a  patient  over  seven- 
teen years  of  age,  in  which  there  was  not  some  shortening.  I  have  had 
cases  shown  to  me  in  which  it  was  averred  that  the  limb  was  not  short- 
ened, but  on  measuring  myself  I  have  found  the  fact  otherwise.  In  chil- 
dren, I  believe  that  union  without  shortening  may  be  accomplished." 
In  a  paper  published  by  Dr.  Lente  in  the  number  of  the  New  York 
Journal  of  Medicine  for  September,  1851,  he  states  that  he  believes 
the  average  shortening  after  treatment  in  the  New  York  City  Hospi- 
tal to  be  three-quarters  of  an  inch ;  but  subsequently,  Dr.  Buck,  one 
of  the  hospital  surgeons,  has  furnished  Dr.  Lente  with  more  exact 
statistics.     Says  Dr.  Buck: — 

"After  carefully  scrutinizing  over  one  hundred  cases  of  fracture  of 
the  femur,  taken  from  the  register  of  the  N.  Y.  Hospital,  and  elimi- 
nating such  as  involved  the  cervix,  or  condyles,  or  belonged  to  the 
class  of  compound  fractures,  there  remained  an  aggregate  of  seventy- 
four  cases,  of  both  sexes,  and  of  all  ages  from  3  to  63,  in  which  the 
shaft  of  the  femur  alone  was  fractured.  In  all  these  cases  the  difter- 
ence  in  the  length  of  the  fractured  limb,  resulting  from  the  treatment, 
was  ascertained  by  careful  measurement  with  a  graduated  tape,  and 
the  following  deductions  were  drawn  from  the  analysis: — 

"Of  the  74  cases  of  all  ages,  19  resulted  without  any  shortening,  a 
proportion  of  about  one-fourth.  The  average  shortening  of  the  re- 
maining 55  cases  was  a  fraction  less  than  three-fourths  of  an  inch. 

"  Seventeen  cases  in  the  above  aggregate  were  under  12  years  of 
age,  of  which  six  resulted  without  any  shortening,  a  proportion  of 
about  one-third.  The  average  shortening  in  the  remaining  11  cases 
was  a  fraction  less  than  one-half  an  inch. 

"  Of  the  57  cases  over  12  years  of  age,  13  resulted  without  any  short- 
ening, a  proportion  of  about  one-fourth ;  and  the  average  shortening 
in  the  remaining  44  cases  was  a  fraction  over  three-fourths  of  an  inch."^ 

'  New  York  Journ.  of  Med.,  second  series,  vol.  xvi.  p.  2G1. 
2  Buffalo  Med.  Journ.,  vol.  xv.  p  23,  June,  1859. 
2t) 


394  FRACTUKES    OF    TPIE    FEMUR. 

It  is  not  to  be  denied,  however,  that  a  few  surgeons  in  all  parts  of 
the  world  have  claimed,  and  still  continue  to  claim,  in  their  own  prac- 
tice, or  from  the  adoption  of  their  own  peculiar  plans  of  treatment, 
much  better  success.  Indeed,  some  of  them  do  not  hesitate  to  affirm 
that,  as  a  general  rule,  any  degree  of  shortening  is  quite  unnecessary. 

Mr.  Amesbury  declares,  that  when  the  fracture  is  in  the  "  middle 
or  lower  third,"  under  a  "judiciously  managed"  application  of  his  own 
splint,  "consolidation  of  the  bone  takes  place  without  the  occurrence 
of  shortening  of  the  limb,  or  any  other  deformity  deserving  of  par- 
ticular notice."' 

Mr.  South,  in  a  note,  commenting  upon  an  opposite  sentiment  ex- 
pressed by  Chelius,  and  already  quoted,  remarks :  "  In  simple  fractures 
of  the  thigh  bone,  except  with  great  obliquity,  I  have  rarely  found 
difficulty  in  retaining  broken  ends  in  place,  and  in  effecting  the  union 
without  deformity,  and  with  very  little,  and  sometimes  without  any, 
shortening.  For  the  contrary  results  the  medical  attendant  is  mostly 
to  be  blamed,  as  they  are  usually  consequent  upon  his  carelessness  or 
ignorance."' 

Mr.  Hunt,  of  the  Queen's  Hospital  at  Birmingham,  who  treats  all 
fractures  with  the  apparatus  immobile  of  Seutin,  has  published  the 
results  of  his  observations;  and  of  the  simple  fractures  of  the  femur 
only  one  presented,  after  the  cure,  any  degree  of  shortening;  and  he 
adds  that  all  other  fractures  which  he  has  treated  by  this  method 
were  followed  by  "  equally  good  results."^  In  relation  to  which  state- 
ments, Mr.  Gamgee  exclaims:  "  This  is  conservative  surgery.  What 
other  mode  of  treatment  would  have  given  such  results?  And  those 
cases  are  not  exceptional.  Mr.  Hunt  tells  us  he  has  selected  them 
from  amongst  many  others  equally  successful.  They  accord  with  the 
experience  recorded  in  my  little  treatise  on  this  subject ;  and  the  works 
of  Seutin,  Burggr^eve,  Crocq,  Velpeau,  and  Salvagnoli  Marchetti 
record  numerous  cases  no  less  remarkable  and  demonstratively  con- 
clusive."" 

Desault,  also,  according  to  the  passage  from  Malgaigne  which  I 
have  already  quoted,  "  pretended  to  cure  all  fractures  without  short- 
ening." I  do  not  find,  however,  any  other  authority  for  this  state- 
ment, as  here  made ;  neither  in  his  Treatise  on  Fractures  and  Luxa- 
tions, edited  by  Bichat,  nor  elsewhere.  Bichat  even  says  positively 
that  "Desault  himself  did  not  always  prevent  the  shortening  of  the 
limb."*  He  declares,  however,  that  "  Desault  has  cured,  at  the  Hotel 
Dieu,  a  vast  number  of  fractures  of  the  os  femoris,  without  the  least 
remaining  deformity."^ 

Dr.  Dorsey,  of  Philadelphia,  who  employed  the  apparatus  of  Desault, 
as  modified  by  Physick  and  Hutchinson  (Fig.  134),  was  equally  suc- 
cessful.'^ 

•  Practical  Remarks  on  Fractures,  by  Joseph  Amesbury.  vol.  i.  p.  384.  London  ed., 
1831.  2  Op!  cit.,  vol.  i.  p.  627. 

3  Researches  on  Pathological  Anatomy  and  Clinical  Surgery,  by  Joseph  Sampson 
Gamgee.     London  ed.,  pp.  159,  160.  *  Op.  cit.,  p.  167. 

5  A  Treatise  on  Fractures  and  Luxations,  etc.,  by  P.  J.  Desault,  edited  by  Xav. 
Bichat.     Amer.  ed.,  p.  251.     1805.  «  Op.  cit.,  p.  223. 

7  Elements  of  Surgery,  by  John  Syng  Dorsey,  vol.  i.  p.  163.   Philadelphia,  1813. 


FRACTUEES  OF  THE  SHAFT  OF  THE  FEMUR.     395 

Dr.  Scott,  of  Montreal,  Professor  of  Clinical  Surgery  in  the  McGill 
College,  and  Physician  to  the  Montreal  General  Hospital,  has  reported 
19  cases  of  fractures  of  the  long  bones,  taken  promiscuously  and 
without  selection,  from  his  hospital  service,  of  which  3  belonged  to 
the  clavicle,  7  to  the  femur,  8  to  the  tibia  and  fibula,  and  1  to  the 
condyles  of  the  humerus.  All  of  which  recovered  without  any  degree 
of  shortening  or  deformity ;  except  the  case  of  fracture  of  the  condyles 
of  the  humerus,  which  resulted  in  death.^ 

Fiff.  134. 


Phtsick's  Splint. — The  splint  is  intended  to  reach  to  the  axilla,  bnt  the  counter-extension  is  made  by 
a  perineal  band.    Physick  employed  a  second,  long,  inside  splint. 

It  is  never  a  pleasant  duty  to  call  in  question  the  accuracy  of 
another's  statements  as  to  what  he  has  himself  alone  seen  and  expe- 
rienced. The  circumstances  which  would  justify  such  an  expression 
of  scepticism,  where  the  witnesses,  as  in  this  case,  are  presumed  to  be 
intelligent  and  honest  men,  must  be  extraordinary.  Such,  however,  I 
conceive  to  be  the  circumstances  in  this  instance.  It  is  certainly  very 
extraordinary  that  a  few  gentlemen  of  acknowledged  skill,  but  whose 
means  and  appliances  are  concealed  from  no  one,  are  able  to  do  what 
nearly  the  whole  world  besides,  with  the  same  means,  acknowledges 
itself  unable  to  accomplish.  Such  is  the  fact,  nevertheless ;  and  our 
lack  of  faith  in  their  testimony  is  only  a  necessary  result  of  our  expe- 
rience, and  of  the  experience  of  the  vast  majority  of  practical  surgeons 
as  opposed  to  theirs. 

I  might  properly  enough  dismiss  this  subject  with  no  farther  argu- 
ment than  may  be  found  in  the  overwhelming  testimony  of  practical 
surgeons,  that  broken  femurs  do  in  their  experience  rarely  unite  with- 
out more  or  less  shortening ;  but  I  cannot  avoid  calling  attention  to 
the  evidence  of  the  falsity  of  the  opposite  opinion,  which  is  furnished 
by  the  testimony  of  the  very  persons  who  themselves  claim  to  have 
obtained  such  fortunate  results. 

It  is  not,  as  might  have  been  supposed,  one  particular  form  of  dress- 
ing, which,  in  itself  peculiar,  and  more  perfect  than  all  others,  has  fur- 
nished these  results.  On  the  contrary,  the  plans  of  treatment  have 
been  constantly  unlike,  and  sometimes  quite  opposite.  Thus,  Desault 
used  a  straight  splint,  with  extension  and  counter-extension,  and  he 
refused  to  adopt  the  flexed  position  recommended  by  Pott,  because 
his  experience,  and  the  experience  of  other  French  surgeons,  bad 
taught  him  its  inutility.^  Adopting  the  straight  position,  he  made 
perfect  limbs;  with  the  flexed  position,  he  found  it  impossible  to  do  so. 

Dorsey  used  the  splint  of  Desault,  as  modified  by  Physick  and 
Hutchinson. 

South,  whose  success  seems  to  have  been  equal  to  that  of  Desault 
or  Dorsey,  adopts  also  the  straight  position ;  but  he  makes  no  perma- 

'  "  Medical  Chronicle"  of  Montreal,  vol.  i.  No.  7,  1853. 
2  Works  of  Desault,  op.  cit.,  p.  23.3. 


iJ 


396 


FRACTURES    OF    THE    FEMTJR. 


nent  extension,  except  what  may  be  accomplished  through  the  medium 
of  four  long  side  splints  applied  after  "gentle"  extension  has  been 
made  by  the  assistants. 

Mr.  Amesbury,  on  the  other  hand,  made  perfect  limbs  only  with  his 
own  double-inclined  plane;  and  speaking  in  general  of  the  various 
plans  hitherto  contrived,  not  excepting  that  invented  by  Desault,  or 
the  method  practised  by  South,  which  had  already  been  recommended 
by  several  surgeons,  he  declares  that  "  they  are  seldom  able  to  prevent 
the  riding  of  the  bone,  and  preserve  the  natural  figure  of  the  limb. 
Indeed,  so  commonly  does  retraction  of  the  limb  occur  under  the  use 
of  the  different  contrivances  usually  employed,  that  I  have  heard  a 
celebrated  lecturer  (now  retired)  in  this  town  publicly  assert  that  he 
never  saw  a  fractured  thigh-bone  that  had  united  without  riding  of 
the  fractured  ends  !"^  And  in  his  "  General  Inferences''' he,  uses  the - 
following  emphatic  language:  "The  contrivances  which  are  com- 
monly used  in  the  treatment  of  these  fractures  do  not  sufficiently 
resist  the  operation  of  the  forces  above  mentioned,  but  suffer  their 
influence  to  be  exerted  upon  the  bone,  in  all  cases  more  or  less  inju- 
riously, and  at  the  same  time  often  assist  in  2^1'oducing  displacement  of 
the  fractured  ends;  so  that  deformity,  differing  in  kind  and  degree  in 
different  cases,  is  almost  the  constant  result  of  fractures  of  the  femur 
treated  by  these  means."^ 

On  the  other  hand,  Mr.  Gamgee  broadly  contradicts  the  statements  of 
Desault,  South,  Dorsey,  and  Amesbury,  and  does  not  hesitate  to  ad- 


Fig.  135. 


^ 


Liston"s  method,  recommended  by  Samuel  Cooper,  Fergassou,  Pirrie,  and  others. 

minister  a  severe  rebuke  even  upon  the  illustrious  Listen :  "  Pott's 
plan,  the  long  splint,  Mclntyre,  and  their  modifications,  as  a  rule  entail 
sensible  deformity,  which  in  many  cases  is  very  considerable.  It  is  a 
significant  fact  that  though  the  example  established  in  University 
College  Hospital  by  the  late  Mr.  Liston,  of  treating  fractures  of  the 
thigh  by  the  long  splint,  and  of  the  leg  by  the  modified  Mclntyre  (a 
double-inclined  plane),  which  are  admitted  equal,  if  not  superior,  to 
other  splints,  was  rigidly  followed  in  that  institution,  the  patients 
admitted  with  broken  thighs  or  legs  were  frequently  discharged  with 
manifest  deformity."^ 

With  how  much  force  Mr.  Gamgee's  own  remarks  as  to  the  expe- 
rience of  the  University  College  Hospital  will  apply  to  the  starched 
bandages  used  by  himself,  the  reader  will  be  able  to  determine  when 
referred  to  the  opinion  of  Velpeau,  already  quoted,  who  claims  no 

'  Amesburj^  on  Fractures,  &c.,  vol.  i.  p.  310.  2  Op.  cit.,  vol.  i.  p.  384. 

^  Advantages  of  the  Starched  Apparatus,  by  Joseph  Sampson  Gamgee.     London, 
1853,  pp.  54,  55. 


FRACTUEES  OF  THE  SHAFT  OF  THE  FEMUR.     397 

result  better  than  an  average  shortening  of  half  an  inch.  ]\r.  Yelpeau 
prefers  and  advocates  the  starched  bandage,  but  he  does  not  claim  to 
be  able  to  prevent  a  shortening  of  the  bone. 

"  What  other  modes  of  treatment  would  have  given  such  results  ?" 
This  question,  propounded,  no  doubt  honestly,  by  Mr.  Gamgee,  has 
here  its  fair  and  satisfactory  answer.  Almost  any  of  the  various 
modes  named ;  for  if  we  must  I'eceive  his  testimony,  we  are  equally 
bound  to  receive  the  testimony  of  Desault,  South,  Dorsey,  Amesbury, 
and  Scott.  If  we  give  credit  to  ]\Ir.  Gamgee,  so  far  as  to  doubt  the 
statements  of  these  latter  as  to  the  degree  of  success  claimed  by  them, 
by  the  same  rule  we  must  doubt  his  own  statements  also  as  to  the 
degree  of  success  claimed  by  himself.  This  I  say  with  all  sincerity 
and  kindness,  fully  believing  that  these  gentlemen  are  mistaken,  and 
not  that  they  intentionally  misrepresent  the  facts. 

By  a  reference  to  my  "  Report  on  Deformities  after  Fractures,"  it 
will  be  seen  that  the  average  shortening  in  fractures  of  the  upper  third 
of  the  femur,  in  the  cases  examined  by  me,  was  about  four-fifths  of  an 
inch ;  in  the  lower  third  it  was  a  fraction  over  three-quarters,  and  in 
the  middle  third  a  fraction  less  than  three-quarters  of  an  inch  ;  and 
the  average  of  the  whole  number  was  almost  exactly  three-quarters 
of  an  inch  (three-quarters  and  -^^).  These  analyses  were  made  upon 
simple  fractures,  and  were  exclusive  of  those  in  which  no  shortening 
at  all  occurred.  An  analysis  which  included  also  those  which  had 
not  shortened,  reduced  the  average  shortening  to  half  an  inch  and 
about  one-tenth. 

An  examination  of  cabinet  specimens  does  not  present  a  result  so 
favorable  even  as  this.  Of  nineteen  fractures  of  the  shaft  of  the  femur 
contained  in  Dr.  Mutter's  cabinet,  not  one  seems  to  have  been  short- 
ened less  than  one  inch.  Specimen  B  63,  fracture  of  the  middle 
third,  is  united  with  a  shortening  of  two  inches  and  a  quarter;  and 
specimen  B  130,  imperfectly  united  after  a  fracture  through  the  mid- 
dle third,  is  overlapped  three  and  a  half  or  four  inches. 

In  conclusion,  I  wish  to  say  briefly  that,  in  view  of  all  the  testimony 
which  is  now  before  me,  I  am  convinced — 

First.  That  in  the  case  of  an  oblique  fracture  of  the  shaft  of  the 
femur  occurring  in  an  adult,  whose  muscles  are  not  paralyzed,  but 
which  offer  the  ordinary  resistance  to  extension  and  counter-extension, 
and  where  the  ends  of  the  broken  bone  have  once  been  cbmpletely 
displaced,  no  means  have  yet  been  devised  by  which  an  overlapping 
and  consequent  shortening  of  the  bone  can  generally  be  prevented. 

Second.  That  in  a  similar  fracture  occurring  in  children  or  in  per- 
sons under  fifteen  or  eighteen  5'-ears  of  age,  the  bone  may  quite  often 
be  made  to  unite  with  so  little  shortening  that  it  cannot  be  detected 
by  measurement;  but  whether  in  such  cases  there  is  in  fact  no  short- 
ening, since  with  children  especially  it  is  exceedingly  difficult  to 
measure  very  accurately,  I  cannot  say. 

Third.  That  in  transverse  fractures,  or  oblique  and  denticulated, 
occurring  in  adults,  and  in  which  the  broken  fragments  have  become 
completely  displaced,  it  will  generally  be  found  equally  difficult  to 
prevent  shortening;  because  it  will  be  found  generally  impossible  to 
bring  the  broken  ends  again  into  such  apposition  as  that  they  will  rest 
upon  and  support  each  other. 


398 


FRACTUEES    OF    THE    FEMUR. 


Fourtb.  That  ia  all  fractures,  whether  occurring  in  adults  or  in 
children,  where  the  fragments  have  never  been  completely  or  at  all 
displaced,  constituting  only  a  very  small  proportion  of  the  whole 
number  of  these  fractures,  a  union  without  shortening  may  always  be 
expected. 

Fifth.  That  when,  in  consequence  of  displacement,  an  overlapping 
occurs,  the  average  shortening  in  simple  fractures,  where  the  best 
appliances  and  the  utmost  skill  have  been  employed,  is  from  half  to 
three-quarters  of  an  inch. 

If  we  consider  the  muscles  alone  as  the  cause  of  the  displacement 
in  the  direction  of  the  long  axis  of  the  shaft,  the  shortening  of  the 
limb,  other  things  being  equal,  must  be  proportioned  to  the  number 
and  power  of  the  muscles  which  draw  upwards  the  lower  fragment. 
This  will  vary  in  different  portions  of  the  limb,  but  nowhere  will  this 
cause  cease  to  operate,  nor  will  its  variations  essentially  change  the 
prognosis. 

I  have  not  intended  to  say  that  other  causes  do  not  operate  occa- 
sionally in  the  production  of  shortening,  but  only  that  muscular  con- 
traction is  the  cause  by  which  this  result  is  chiefly  determined,  and 
that  its  power  will  be  ordinarily  the  measure  of  the  shortening. 

Treatment. — All  the  early  surgeons,  so  far  as  we  know,  adopted 
the  straight  position  in  the  treatment  of  fractures  of  this  bone  ;  either 
with  simple  lateral  splints,  or  with  long  splints,  with  or  without  exten- 
sion, or  with  only  rollers  and  compresses,  or  with  extension  alone. 

Such  was  the  unanimous  opinion  and  practice  of  surgeons  until 
about  the  middle  of  the  last  century,  at  which  time  Percival  Pott  wrote 
his  remarkable  treatise  on  fractures  ;  a  work  distinguished  for  the  origi- 
nality and  boldness  of  its  sentiments,  and  which  was  destined  soon  to 
,  revolutionize,  especially  throughout  Great  Britain,  the  old  notions  as 
to  the  treatment  of  fractures,  and  to  establish  in  their  stead,  at  least  for 
a  time,  what  has  been  called,  not  inappropriately,  the  "  physiological 
doctrine;"  the  peculiarity  of  which  doctrine  consisted  in  its  assump- 
tion that  the  resistance  of  those  muscles  which  tend  to  produce  short- 
ening can  generally  be  sufficiently  overcome  by  posture,  without  the 
aid  of  extension ;  and  that  for  this  purpose,  for  example,  in  the  case 
of  a  broken  femur,  it  was  only  necessary  to  flex  the  leg  upon  the  thigh, 
and  the  thigh  upon  the  body,  laying  the  limb  afterwards  quietly  on 
its  outside  upon  the  bed. 

Very  few  surgeons,  even  of  his  own  day,  ever  gave  in  their  full  ad- 
hesion to  the  exclusive  physiological  system  as  taught  and  practised 


Fia;.  136. 


Double-inclined  plane  employed  in  Middlesex  Hospital,  Loudon. 


FRACTURES  OF  THE  SHAFT  OF  THE  FEMUR. 


399 


by  Pott  himself;  but  multitudes,  especiallj^  among  the  English,  adopted 
in  general  his  views,  only  choosing  to  place  the  patients  upon  their 
backs  rather  than  upon  their  sides,  and  laying  the  limbs  flexed  over  a 
double-inclined  plane.  To  the  support  of  this  system  of  Pott's,  thus 
modified,  Sir  Astley  Cooper,  C.  Bell,  John  Bell,  Earle,  White,  Sharp, 
and  Amesbury  lent  the  influence  of  their  great  names,  and  its  triumphs, 
so  far  as  the  judgment  of  British  surgeons  was  concerned,  soon  became 
complete. 

Fi"r.  137. 


Amesbury's  spliat. 


In  France,  and  upon  the  continent  generally,  the  reception  of  this 
system  was  more  slow  and  reluctant;  but  Dupuytren,  now  for  once 
taking  ground  with  his  great  rival.  Sir  Astley,  adopted  almost  without 
qualification  these  novel  views.     The  decision  of  Dupuytren  deter- 


Ficr.  138. 


Amesbury's  spliat  applied. 

mined  the  opinions  of  a  large  portion  of  the  continental  surgeons ; 
and  had  it  not  been  for  the  early  and  decisive  opposition  of  Desault 
and  Boyer,  the  great  surgeon  of  St.  Bartholomew  might  have  con- 
tinued for  a  long  time  to  have  enjoyed  a  triumph  upon  the  continent, 
and  perhaps  throughout  the  world,  equal  to  that  which  had  already 
been  decreed  to  him  in  Great  Britain. 

On  this  side  of  the  Atlantic,  the  practice  of  Pott,  at  least  in  so  far 
as  it  applied  to  the  treatment  of  fractures  of  the  thigh,  never  gained 


Boyer's  splint. 


400 


FEACTUKES    OF    THE    FEMUE. 


a  distinguished  advocate;  and  but  few  ever  adopted  tbe  practice  as 
modified  by  White,  Amesbury,  Bell,  A.  Cooper,  &c. 

But  whatever  may  have  been  the  early  success  of  these  doctrines, 
either  here  or  elsewhere,  it  is  certain  that  a  strong  reaction  has  taken 
plaec,  and  that  gradually,  in  all  parts  of  the  world,  the  opinions  of 
practical  surgeons  have  been  settling  back  into  their  old  channel.  It 
would  be  difficult  to  find  to-day,  in  France  or  Germany  a  dozen  dis- 
tinguished surgeons  who  adopt  universally  the  flexed  position  in  the 
treatment  of  fractures  of  the  femur;  and  in  England  the  reaction  is, 
if  possible,  even  more  complete. 

In  my  tour  of  1844,  during  which  I  visited  very  many  of  the  hos- 
pitals of  Great  Britain  and  upon  the  continent  of  Europe,  I  do  not 
remember  to  have  seen  the  flexed  position  once  employed  in  the  treat- 
ment of  a  broken  thigh ;  and  I  shall  presently  show  that  the  straight 
position  is  at  the  present  moment  very  generally  adopted  by  the  best 
American  surgeons. 

There  have  been,  then,  three  grand  epochs  in  the  history  of  the 
treatment  of  fractures  of  the  thigh. 

First.  That  in  which  the  straigiit  position  was  universally  adopted, 
and  which  reaches  from  the  earliest  periods  to  the  period  of  the  writ- 
ings of  Pott,  or  to  about  the  middle  of  the  last  century. 

Second.  The  epoch  of  the  flexed  position,  which,  inaugurated  by 
Pott,  had  already  begun  to  decline  at  the  beginning  of  the  present 
century,  and  which  may  be  said  to  have  been  completed  within  less 
than  one  hundred  years  from  the  date  of  its  first  announcement. 

Third.  The  epoch  of  the  renaissance,  or  that  in  which  surgeons,  by 
the  vote  of  an  overwhelming  majority,  have  declared  again  in  favor 
of  the  straight  position.     This  is  the  epoch  of  our  own  day. 

Although  American  surgeons  have  generally  adopted  the  straight 
position  in  the  treatment  of  fractures  of  the  thigh,  yet  the  form  and 
construction  of  the  splints  employed  have  been  greatly  varied.  The 
simple  long  splint  of  Desault,  and  the  more  complicated  apparatus  of 
Boyer  (Fig.  139),  have  each  their  advocates;  but  it  is  seldom  that  we 
meet  with  these  or  with  any  of  the  other  forms  of  apparatus  originally 
employed  in  foreign  countries  without  noticing  that  they  have  been 
subjected  to  considerable  modifications;  indeed,  most  of  the  straight 


Fiir.  140. 


Nathan  K.  Smith's  suspending  apparatus,  or  uoubie-inclined  plane. 


FRACTURES  OF  THE  SHAFT  OF  THE  FEMUR. 


401 


splints  as  well  as  double-inclined   planes  in  use  at  present    among 
American  surgeons  may  fairly  be  regarded  as  original  inventions. 

Nathan  Smith,  of  New  Haven  ;^  Nathan  R.  Smith,  of  Baltimore  f 
Sayre,  of  New  York;  McNaughton,  of  Albany  f  and  Nott,  of  Mobile, 
are  the  only  American  surgeons  of  distinguished  reputation,,  and  with 
whose  practice  I  am  familiar,  who  have  recommended  exclusively  the 
double-inclined  plane. 

Fisr.  141. 


JosiAH  C.  Nott's  Double-inclined  Plane. 
In  this  ajiparatus  the  limb  is  secured  to  the  splint  by  vertical  pins  and  leather  straps;  the  upper  sur- 
face of  the  thigh  splint  is  carved  out  a  little,  to  fit  the  thigh  ;  the  two  portions  are  articulated  by  a  joint 
lilie  that  of  a  carpenter's  rale,  and  this  joint  may  be  steadied  by  a  horizontal  bar  underneath.     For  the 
rest,  the  drawing  sufficiently  explains  itself. 

Dr.  Nathan  R.  Smith  has  introduced  a  modification  of  the  double- 
inclined  plane  in  what  is  known  as  his  "anterior  splint,"  and  which 
is  intended  also  as  a  suspending  apparatus,  I  have  seen  it  employed 
lately  a  good  deal  in  the  treatment  of  gunshot  fractures  of  the  thigh 
and  leg  in  our  various  military  hospitals.  It  is  my  opinion,  how- 
ever, that  it  is  more  applicable  to  gunshot  fractures  of  the  leg  than 
to  those  of  the  thigh. 

The  splint,  if  splint  it  can  be  properly  called,  is  simply  a  frame 
composed  of  stout  wire  and  covered  with  cloth,  which  being  suspended 
above  the  limb,  allows  the  limb  to  be  suspended  in  turn  to  it  by  rollers; 
the  rollers  passing  around  both  limb  and  splint  from  the  foot  to  the 
groin.     Wire  of  the  size  of  No.  10  bougie  is  usually  employed.     Tho'' 

Fiff.  142. 


N.  R.  Smith's  anterior  splint. 

length  of  the  splint  should  be  sufficient  to  extend  from  above  the 
anterior  superior  spinous  process  of  the  ilium  to  a  point  beyond  the 
toes,  the  lateral  bars  being  separated  about  three  inches  at  the  top  and 
one-quarter  of  an  inch  less  at  the  lower  extremity. 

'  Amer.  Med.  Rev.,  published  at  Philadelphia,  1825,  vol.  ii.  p.  355  ;  also  Medical 
and  Surgical  Memoirs  of  Nathan  Smith,  published  at  Baltimore,  pp.  129-141. 

2  Med.  and  Surg.  Memoirs,  pp.  143-162.    See  also  Geddings,  Baltimore  ]\Ied.  and 
Surg.  Journ.,  vol.  i.,  1833  ;  and  Sargent's  ]\rinor  Surgery,  p.  171 

3  Trans.  Amer.  Med.  Assoc,  vol.  x.  p.  317.     Rep.  on  Detbr.  after  Frac. 


402 


FRACTUEES    OF    THE    FEMUR. 


In  the  case  of  a  broken  thigh,  the  upper  hook,  to  which  the  cord 
for  suspension  is  to  be  fastened,  ought  to  be  nearly  over  the  seat  of 
fracture,  and  the  lower  hook  should  be  placed  a  little  above  the  middle 
of  the  leg. 

Fig.  143. 


N.  R.  Smith's  aaterior  splint,  applied  for  a  fracture  of  the  thigh. 

Fig.  144. 


Palmer's  modification  of  the  anterior  splint. 


FRACTURES  OF  THE  SHAFT  OF  THE  FEMUR.     403 

The  modification  of  Smith's  anterior  splint  suggested  by  Dr.  James 
Palmer,  United  States  Navy,  will  be  sufficiently  explained  by  the 
accompanying  wood-cut,^  Fig.  IM. 

Dr.  J.  S.  Hodgen,  of  St.  Louis,  Mo.,  has  invented  a  wire  suspension 
splint,  which  I  much  prefer  to  Smith's.  The  bars  of  wire  are  traversed 
with  a  cotton  sacking,  upon  which  the  limb  is  laid.  He  does  not, 
however,  advocate  its  general  use,  but  he  has  designed  it  especially 
for  gunshot  fractures.^ 

Fiar.  145. 


Hodgen's  suspension  apparatus. 

On  the  other  hand,  among  the  advocates  of  the  straight  position 
are  found  the  names  of  Physick,  Dorsey,  Gibson,  Horner,  J.  Harts- 
horne,  H.  H.  Smith,  Neill,  E,  Coates,  H.  Hartshorne,  Norris,  Gross. 

Says  Dr.  Gross :  "Many  years  ago,  before  I  had  much  experience  in 
this  class  of  injuries,  I  occasionally  employed  the  flexed  position,  but 
I  soon  found  that  it  was  objectionable,  on  account  of  the  great  difficulty 
in  maintaining  so  accurate  apposition  to  the  ends  of  the  fragments.  Of 
late  years  I  have  confined  myself  entirely  to  the  use  of  the  straight 
position,  and  I  have  never  had  any  cause  to  regret  it.  In  the  adult,  I 
sometimes  employ  the  apparatus  of  Desault,  as  modified  by  Physick, 
but  much  more  frequently  one  of  my  own  construction,  somewhat 
upon  the  principle  of  that  of  Dr.  Neill,  described  in  the  Philadelphia 
Medical  Examiner  for  1855.  I  have  used  it  for  nearly  twenty  years, 
and  it  has  generally  answered  the  purpose  most  admirably  in  my 
hands.  It  consists  simply  of  a  box  for  the  thigh  and  leg,  with  a  foot- 
piece  and  two  crutches,  one  for  the  axilla  and  the  other  for  the  peri- 
neum, to  make  the  requisite  extension  and  counter-extension.  With 
such  an  apparatus,  an  oblique  fracture  of  the  thigh  can  be  treated  with 
great  comfort  to  the  patient,  and  with  the  assurance  of  a  good  limb. 
In  children,  I  have  effected  some  excellent  cures  simply  by  means  of 
a  sole-leather  trough,  well  padded,  and  provided  with  a  foot  piece. 

>  Amer.  .Journ.  Med.  Sci.,  1865;  also,  Mechanical  Therapeutics,  etc.,  by  Philip 
S.  Wales,  M.D.,  U.S.N.,  1867. 
2  Hod.i^en,  Treatise  on  Mil.  Surg.,  by  F.  H.  Hamilton,  1865,  p.  411. 


404 


FRACTURES    OF    THE    FEMUR, 


"  The  great  objection  to  the  flexed  position  is  the  difficulty  of  keep- 
ing the  ends  of  the  broken  bones  in  apposition  ;  the  upper  one  having 
a  constant  tendency  to  pass  away  from  the  inferior.     Other  objections 

Fig.  146. 


John  Neill's  Straight  Thiqh-Splint— Exteasion  and  counter-extension  made  at  the  same  time. 


might  be  urged  against  the  flexed  position,  but  this  is  quite  sufficient 
to  induce  me  to  reject  it."^ 


Fiff.  147. 


Fi!?.  148. 


Pelvic  belt,  and  perineal  strap.     (From  drawings  fur- 
nished by  Dr.  L.  M.  Sargent,  Boston,  Mass.) 


Foot-piece  and  screw. 


.     Fitr.  149. 


Lateral  view  of  the  apparatus,  without  the  belt. 


Fiff.  loO. 


Front  view,  with  folded  sheet  laid  across 


'  Trans.  Am.  Med.  Assoc,  vol.  x. ;  also  System  of  Surg.,  by  S.  D.  Gross,  1839, 
p.  221. 


FRACTURES  OF  THE  SHAFT  OF  THE  FEMUR.     405 
Fig.  151. 


Apparatus  applied 

Tier.  152. 


fi — iiTTi   r 


f:'^..i^Tf^  rTiiPiT^i    \4 


Side  view  of  apparatus  applied. 

Fig.  153. 


Fig.  154. 


Fio»  lo3,  1  A      Mode  of  making  extension  with  adhesive  plaster. 

Dr.  Neill,  of  Philadelphia,  has  contrived  a  very  ingenious  mode  of 
making  both  extension  and  counter-extension  at  the  same  moment  by 
means  of  a  twisted  rope  which  is  fastened  by  its  two  ends  respectively 
to  the  perineal  band  above  and  the  extending  bands  below. 

J.  F.  Flagg's  thigh  apparatus,  as  used  in  the  Massachusetts  General 
Hospital,  by  Warren,  Bigelow,  and  others  (Figs.  l-i7  to  15-1  inclusive). 

"  The  belt  is  made  of  strong  webbing,  having  pockets  on  each  side, 
to  receive  the  long  splint.  It  is  also  furnished  with  straps  and  buckles. 
The  perineal  strap  (Fig.  155),  corresponding  to  the  injured  side,  is 
kept  constantly  buckled,  while  the  other  may  be  occasionally  loosened, 
or  left  off",  as  its  purpose  is  only  to  steady  the  apparatus.  Where  the 
straps  pass  under  the  perineum,  they  are  covered  with  wash-leather. 
Before  applying  the  belt,  a  pillow-case  or  two  may  be  passed  around  the 
waist.  The  padlock  is  only  to  be  used  in  case  the  patient  persists  in 
unbuckling  the  straps.  The  splints  being  applied  with  also  short 
side  splints,  junks,  containing  bran  or  sand,  &c.,  are  to  be  secured 
more  firmly  to  the  limb  by  bands  of  webbing  and  buckles." 

The  two  Warrens,  father  and  son,  of  Boston,  Kimball,  of  Lowell, 
Sanborn,  of  Lowell,  Mass.,  Mussey,  of  Cincinnati,  Ohio,  J.  B.  Flint,  of 


406 


FRACTURES    OF    THE    FEMUR. 


Louisville,  Kj,,  Armsby,  of  Albany/  have  also  recommended  some 
form  of  the  straight  splint.     Says  Dr.  Mussey: — 

"  For  all  fractures  of  the  thigh-bone  I  employ  the  extended  position 
of  the  limb.     There  are  but  few  cases  in  which  extending  force  is  not 


Fig.  155. 


Fig.  156. 


I 


Perineal  band  secured  with  a  padlock. 

necessary  to  prevent  the  degree  of  deformity  or 
shortening  which  would  occur  without  it.  Of  thirty 
specimens  of  fracture  of  the  shaft,  in  my  collection, 
only  two  are  transverse.  In  fractures  of  the  neck, 
especially  with  old  subjects,  I  sometimes  avoid  the 
application  of  any  kind  of  apparatus  for  permanent 
extension ;  but  in  all  cases,  whether  of  the  neck  or 
shaft,  where  such  extension  is  attempted,  I  have 
found  the  straight  position  of  the  limb  to  be  the 
most  reliable." 

And  Dr.  Kimball,  who  employs  generally  San- 
born's splint,  uses  the  following  emphatic  lan- 
guage :— 

"  If  I  should  be  asked  under  what  circumstances 
I  would  use  the  double-inclined  plane  in  case  of 
fracture  of  the  femur,  I  would  unhesitatingly  an- 
swer,never !  I  have  long  since  abjured  the  double- 
inclined  plane  in  every  form  of  fracture  of  this  bone, 
finding  the  straight  splint  fully  adequate  to  all  pur- 
poses for  which  any  apparatus  of  this  kind  is  re- 
quired. In  support  of  this  statement,  I  could 
furnish  a  great  number  of  cases  showing  that  the 
locality  of  the  fracture,  the  importance  of  which  is 
so  much  dwelt  upon  in  the  books,  constituted  in 
no  case  a  valid  objection  to  its  use." 

Extension  in  Sanborn's  apparatus  is  effected  by  means  of  adhesive 
straps,  and  counter-extension  by  a  perineal  band;  but  the  patient 
may  at  any  moment  relieve  the  pressure  in  the  perineum  by  resting 
his  axilla  upon  the  head  of  the  crutch.  - 

Daniell,  of  Savannah,  Georgia,  recommends  the  straight  position,  the 


Sanborn's  Splint,  a. 
The  movable  crutch,  b. 
The  screw  which  flexes 
the  crutch,  c.  The  cross- 
bar to  which  the  ends 
of  the  strap  are  fastened. 
d.  The  moving  screw. 


'  Trans.  Am.  Med.  Assoc,  vol.  x.     Report  on  Deformities  after  Fractures 


FRACTURES  OF  THE  SHAFT  OF  THE  FEMUR. 


407 


limb  being  laid  in  a  kind  of  long  box,  and  the  extension  being  made 
with  a  weight  and  pulley.^  Dugas,  of  Augusta,  Georgia,  employs  the 
pulley  and  weight  also,  but  uses  the  long  side  splint  instead  of  the 
box.^     Howe,  of  Boston,  recommended  a  similar  method  in  1824.^ 

Dr.  Gurdon  Buck,  of  New  York,  uses  the  pulley,  without  the 
long  side  splint.  Ilis  perineal  band  is  composed  of  India-rubber 
tubing,  "of  one  inch  calibre,  two  feet  in  length,"  stuffed  with  bran  or 
cotton  lampwick,  and  covered  with  canton  flannel,  which  covering 
may  be  renewed  as  often  as  may  be  necessary.  The  extending  bands 
or  adhesive  plasters  terminating  below  the  foot  in  an  elastic  rubber 

Fiff.  157. 


Gurdon  Buck's  apparatus. 


make  suitable  extension  will 


vary 


cord.     The  weight  necessary  to 
from  five  to  twenty  pounds. 

Wm.  E.  Horner,  of  Philadelphia,  employed  a  long  outside  splint 
extending  into  the  axilla,  and  padded,  so  as  to  avoid  the  necessity  of 
junks;  with  fenestrse,  for  extending  and  counter-extending  bands; 
and  also  a  foot-piece;  and  a  short  inside  splint,  made  to  extend  from 
the  perineum  to  the  bottom  of  the  foot.     Across  the  excavated  upper 


Fiff.  158. 


W.  E.  Horuer's  thigh-splint. 

end  of  this  splint,  a  strip  of  leather  is  stretched  to  receive  the  pressure 
of  the  perineum,  while  the  perineal  band  is  made  to  pass  through  two 
firm  leather  loops  on  the  outside  of  the  splint.* 

'  Amer.  Jonrn.  Med.  Sciences,  vol.  iv.  p.  330,  1839. 

2  Southern  Med.  and  Surg.  Journ.,  Feb.  1854. 

3  Howe,  New  Eng.  Med.  Journ.,  July,  1824. 

*  Treatise  on  the  Practice  of  Surgery,  by  Henry  H.  Smith. 


408 


FKACTUEES    OF    THE    FEMUE. 


Dr.  Joseph  E.  Hartshorne,  of  Philadelphia,  rejected  the  perineal 
band  altogether,  and  sought  to  make  the  counter-extension  by  means 
of  the  internal  long  splint  alone;  and  for  this  purpose  he  cushioned 
the  head  of  the  inside  splint,  as  will  be  seen  in  the  accompanying 
drawing.     The  head  of  the  outside  splint  may  also  be  cushioned,  but 


Fis.  159. 


Joseph  Hartshorue's  thigh-splint. 


not  for  the  purpose  of  employing  it  as  a  means  of  counter-extension. 
The  outside  splint  is  so  adjusted  to  the  foot-piece,  that  U  may  be  re- 


Fiff.  IGO. 


D.  Gilbert's  Mode  of  making  Codnteb-extension,  and  Extenston. 
1.  Anterior  and  posterior  counter-extending  adhesive  bands,  two  and  a  half  inches  wide,  crossing  each 
other  before  they  pass  through  the  mortise  holes.     2.  The  same  crossing  at  the  upper  part  of  thigh  and 
perineum.     3.  Horizontal  pelvic  band,  which  may  be  three  inches  wide.     4.  Extending  bauds,  receiving 
strap  of  tourniquet  in  the  hollow  of  the  foot.     5.  Tourniquet. 

Fijr.  IGl. 


Gilbert's  APPARATrs  applied  in  a  Casi;  of  FRACirEE  of  both  Thiohs. 

1.  Anterior  adhesive  counter-extending  strips.  2.  Di.stal  extremity  of  posterior  adhesive  strip  of 
the  side  3.  Adhesive  strip  surrounding  pelvis,  binding  the  anterior  and  posterior  strips  to  pelvis.  4. 
Inner  extremity  of  the  extending  adhesive  strip,  forming  stirrup  under  the  foot,  to  receive  the  strap  of 
the  tourniquet.     5.  Cicatrix  of  left  thigh.     7,  7.  Petit's  tourniquet,  by  which  the  power  was  applied. 

moved  in  case  of  a  compound  fracture,  without  disturbing  either  the 
extension  or  counter-extension.^ 


'  Treatise  on  the  Practice  of  Snrgerj',  by  Henry  H.  Smith. 


FRACTURES  OF  THE  SHAFT  OF  THE  FEMUR. 


409 


Dr.  David  Gilbert,  of  Philadelphia,  has  published  an  account  of  a 
method  of  making  counter-extension  with  adhesive  strips,  which  he 
had  employed  successfully  not  only  in  fractures  of  the  thigh,  but  also 
of  the  leg;  extension  being  made  with  the  tourniquet  of  Petit.  A 
broad  piece  of  plaster  also  is  made  to  encircle  the  pelvis,  in  order  to 
bind  down  the  counter-extending  bands  more  firmly  to  the  body. 
Additional  strips  are  employed  when  they  seem  to  be  required.' 

H.  L.  Hodge,  also  of  Philadelphia,  adopting  the  same  means  of 
counter-extension,  namely,  adhesive  plaster  bands,  has  modified  the 
idea  of  Gilbert  by  securing  the  strips  of  plaster  to  the  sides  of  the 
body  instead  of  the  perineum,  and  attaching  them  to  an  iron  rod 
which  is  made,  to  project  from  the  top  of  the  splint  beyond  the 
shoulders.^ 

Fio;.  162. 


H.  L.  Hodge's  method  of  counter-extension  in  fracture  of  the  femur. 

Lente,  of  New  York,  has  also  occupied  himself  in  the  construction 
of  an  apparatus  by  which  he  hopes,  in  some  measure,  to  obviate  the 
inconveniences  of  the  perineal  band,  by  distributing  the  pressure 
between  the  tuberosity  of  the  ischium  and  the  groin.  He  has,  there- 
fore, supplied  his  splint  with  an  iron  brace,  extending  in  a  curved 
line  from  the  upper  part  of  the  external  splint,  directly  across  the 
body,  to  the  median  line,  and  cushioned  on  its  inner  surface.  To  this 
is  attached  the  anterior  extremity  of  the  perineal  band.  By  this 
arrangement  the  pressure  is  not  only  in  a  great  measure  removed 
from  the  groin,  and  from  the  vessels,  etc.,  on  the  inside  of  the  thigh, 
but  also  the  direction  of  the  counter-extension  is  in  a  line  with  the 
axis  of  the  body.  The  posterior  extremity  of  this  band  is  secured, 
not  to  the  upper  end  of  the  splint,  as  is  usually  done,  but  to  the  splint 
several  inches  lower  down,  where  it  will  take  a  more  secure  hold 
upon  the  under  surface  of  the  tuberosity  and  nates.  Both  extremities 
of  the  band  are  elastic.  Extension  is  made  with  a  screw,  inclosing 
a  strong  spiral  spring  in  its  ferrule,  or  with  adhesive  plasters,  a  pulley 
and  weight,  at  the  option  of  the  surgeon. 


27 


'  Gilbert,  Amer.  Jonrn.  Mod.  Sci.,  April,  1859.  pp.  410-424. 
2  Hodge,  Amer.  Jourii.  Med.  Sci.,  April,  18G0. 


410 


FRACTURES    OF    THE    FEMUR. 


The  splint  is  made  in  sections,  for  adaptation  to  different  persons, 
and  for  convenience  in  packing.  It  extends  no  higher  than  the  alae 
of  the  pelvis,  and  is  secured  to  the  body  at  this  point  by  a  padded 
pelvic  band.  The  accompanying  illustration  will  sufficiently  explain 
the  remaining  features  of  the  apparatus. 


Fi-  163. 


Lente's  thigli-spliut. 


The  apparatus  invented  by  Dr.  Burge,  of  Brooklyn,  is  both  a  frac- 
ture-bed and  a  splint,  and  was  constructed  with  the  same  view  of 
removing  pressure  from  the  front  of  the  groin.     The  principles  in- 


Fiir.  104. 


Burge's  apparatus. 


volved  and  the  general  plan  of  construction  will  be  sufficiently  ex- 
plained by  a  study  of  the  accompanying  wood-cuts. 


FEACTURES  OF  THE  SHAFT  OF  THE  FEMUR. 


411 


There  are  a  few,  however,  of  our  most  distinguished  surgeons,  Avho 
retain  the  flexed  position  in  certain  fractures,  such  as  an  oblique 
downward  and  forward  fracture,  occurring  just  below  the  trochanter 
minor,  and  a  similar  fracture  just  above  the  condyles,  or  in  certain 


Fis;.  165. 


*HAiUiy    iTt* 


Burge's  apparatus  applied. 

cases  of  fractures  in  children,  or  in  very  old  people,  but  who,  never- 
theless, give  a  decided  preference  to  the  straight  splint  in  those  oblique 
fractures  of  the  shaft  which  constitute  by  far  the  greatest  proportion 
of  all  these  accidents.  Among  these,  I  will  mention  the  names  of 
Nott,  of  New  York;  Pope,  of  St.  Louis,  Mo.,  and  Eve,  of  iNTashville, 
Tenn. 

The  practice  of  Dr.  Pancoast,  of  Philadelphia,  is  peculiar,  and  will 
be  best  described  by  himself: — 

"  I  treat  all  thighs,  fractured  in  their  middle  part,  by  the  long  splint, 
and  in  the  straight  position.  In  fractures  occurring  at  either  end  of 
the  bone  I  resort  at  first  to  the  angular  splint  and  the  flexed  position, 
and  thus  place  the  muscles  more  at  rest ;  in  which  position,  also,  there 
is  less  tendency  to  angular  displacement  and  shortening.  After  the 
lapse  of  a  few  days,  when  the  disturbed  muscles  have  lost  their  ten- 
dency to  spasm,  and  the  hardened  cellular  tissue  about  the  fracture 
has  formed  a  sort  of  bond  between  the  ends  of  the  broken  bone,  I 
gently  bring  the  limb  down  to  the  straight  position,  and  apply  the 
long  splint."^ 

The  practice  of  treating  fractures  of  the  thigh,  as  well  as  all  other 
fractures  of  the  long  bones,  with  the  roller  alone,  and  without  either 
lateral  splints  or  extending  apparatus,  first  suggested  by  Radley,  has 
found  in  this  country  but  one  distinguished  advocate,  the  late  Dr. 
Dudley,  of  Lexington,  Ky.^  Nor,  with  all  my  respect  for  that  truly 
great  surgeon,  can  I  persuade  myself  that  the  practice  is  able  to  ac- 
complish, in  a  majority  of  cases,  the  indications  proposed,  nor  indeed 
that  it  is,  at  least  in  the  hands  of  inexperienced  surgeons,  wholly  safe. 

'  Trans.  Amer.  Med.  Assoc,  vol.  x.     Rep.  on  Def..  etc. 

2  Amer.  Journ.  of  the  Med.  Sci  ,  vol.  xix.  p.  270  ;  Transylvania  Journal,  April, 
183G.  Boston  Med.  and  Surg.  Journ.,  vol.  xxxiv.  p.  35. 


412  FRACTURES    OF    THE    FEMUR. 

Dr.  D.,  of  Aberdeen,  Miss.,  has  reported  to  me  one  example  in  which, 
after  the  application  of  this  bandage  by  a  pupil  of  Dr.  Dudley's,  to  a 
negro  slave,  who  had  a  fracture  of  the  femur,  death  of  the  limb  ensued, 
and  amputation  became  necessary.  The  negro  was  sixteen  years  old, 
and  healthy ;  the  fracture  was  caused  by  the  fall  of  a  tree  or  of  a 
branch,  and  was  simple.  The  bandage  was  applied  from  the  toes  up- 
wards to  the  groin,  and  was  not  opened  for  several  days,  at  which  time 
the  whole  limb  was  found  to  be  in  a  state  of  dry  gangrene,  with  the 
exception  of  the  upper  two-thirds  of  the  thigh,  which  was  swollea 
enormously,  and  partially  gangrenous  as  high  up  as  the  groin. 

Dr.  D.  says :  "  Having  heard  the  history  of  the  case  carefully 
stated,  observing  the  leg  and  the  lower  part  of  the  thigh  to  be  in  a 
state  of  dry  gangrene,  and  seeing  the  marks  of  the  bandage  visibly 
impressed  on  the  surface,  ray  opinion  was  made  up  at  the  time  that 
the  gangrene  had  resulted  from  pressure  of  the  bandage.  The  femoral 
artery  at  the  groin  was  in  a  sound  and  natural  state,  and  if  I  mistake 
not,  after  the  limb  was  removed,  it  was  traced  to  the  point  of  oblite- 
ration where  the  gangrene  commenced,  and  where  the  impression  of 
the  bandage  was  observed;  thus  far,  I  think,  it  was  of  natural  size 
and  calibre.  Hence  the  conclusion  is  inevitable,  that  the  death  of 
the  limb  resulted  from  the  pressure  of  the  bandage,  and  not  of  one  of 
the  fragments. 

"  It  was  a  curious  specimen  of  dry  mortification,  and  I  regret  that  I 
did  not  use  the  means  of  preserving  it.  I  was  then  engaged  in  a  very 
laborious  practice,  thirty  miles  from  home,  on  horseback,  and  conse- 
quently could  not  conveniently  spare  the  time  to  attend  to  it  as  an 
object  of  surgical  curiosity.  Dr.  H.  and  myself  cut  into  the  leg  in 
various  places,  in  order  to  examine  the  muscles,  arteries,  nerves,  etc., 
but  found  the  integuments  so  hard  that  it  was  really  difficult  to  pene- 
trate them  with  a  knife ;  the  resistance  to  the  knife  was  more  like 
that  of  dry  hickory  wood  than  anything  else."^ 

I  cannot  think  it  necessary  to  do  more  than  allude  to  the  practice 
of  Jobert,  of  Paris,  and  of  Swinburn,  of  Albany,  who,  rejecting  side 
or  coaptation  splints  altogether,  have  relied  solely  upon  extension  as 
a  means  of  support  and  retention  in  the  case  of  fractures  of  the  shaft 
of  the  femur. 

The  treatment  of  these  and  other  fractures  by  plaster  of  Paris,  paste, 
starch,  or  dextrine  has  been  already  considered  when  speaking  of  the 
treatment  of  fractures  in  general.  Thus  far  my  experience  will  not 
warrant  me  in  recommending  the  immovable  apparatus  as  a  general 
plan  of  treatment  in  any  other  cases  than  fractures  of  the  leg  below 
the  knee.  Yet  I  must  in  candor  admit  that  in  the  hands  of  Drs. 
Bryant,  Synott,  Alexander,  O'Byrne,  and  St.  John,  house  surgeons  at 
Bellevue,  the  plaster  of  Paris  dressing  for  broken  femurs  has  been 
attended  with  a  greater  than  average  success.  I  have  before  me  a 
paper  now  in  preparation  for  the  press,  by  Dr.  J.  D.  Bryant,  and  from 
which  it  appears  that  of  21  cases  treated  by  this  method  at  Bellevue, 

'  For  a  more  complete  account  of  this  interesting  case,  see  Buffalo  Med.  Journal, 
vol.  xiv.  p.  I'JS,  Sept.  18j8. 


FEACTTTRES    OF    THE    SHAFT    OF    THE    FEMUE. 


413 


11  united  without  any  apparent  shortening,  and  10  with  an  average 
shortening  of  three-eighths  of  an  incli.  Of  the  11  perfect  results,  5 
were  obtained  in  persons  over  IS  years  of  age. 

For  the  accuracy  of  the  statements  made  in  this  paper  I  am  pre- 
pared to  vouch  ;  but  the  facts  are  nevertheless  inconclusive.  Similar 
results,  or  results  very  nearly  equal,  may  be  obtained  in  a  hospital 
where  great  care  is  exercised  and  the  best  skill  is  applied,  by  my  own 
method,  and  without  any  possibility  of  accidents.  At  Bellevue,  as 
Dr.  Bryant's  report  will  show,  accidents  have  occurred  in  the  use  of 
the  plaster,  and  of  a  pretty  serious  nature;  and  that,  too,  notwith- 
standing the  gentlemen  in  charge  possess  unusual  qualifications,  and 
have  been  exceedingly  vigilant. 

Fio;.  106. 


Extension  during  application  of  plaster  of  Paris. 


Possibly,  in  some  degree,  the  results  obtained  by  these  gentlemen 
may  be  due  to  the  mode  adopted  by  them  of  making  extension  while 
the  plaster  was  being  applied.  In.  ten  cases  the  patients  were  under 
the  influence  of  an  anaesthetic  during  the  reduction  and  dressino-,  and 
of  these,  four  united  without  shortening;  in  all  the  cases  extension  was 
made  in  the  following  manner,  or  in  a  manner  very  nearly  such  as 
I  shall  now  describe. 

A  plaster  of  Paris  bandage  having  been  applied  to  the  foot  and  leg 
some  hours  before,  or  sufficiently  long  to  permit  it  to  harden,  a  noose 
was  placed  about  the  ankle  for  the  purpose  of  attaching  the  pulleys. 
The  patient  was  now  placed  with  his  nates  overhanging  one  corner 
of  the  bed  or  table,  and  with  the  perineum  resting  against  an  upright 
stanchion  wound  with  woollen  cloth.  The  pelvis  w^as  then  lifted  by 
a  broad  band  tied  over  a  cross-bar  resting  upon  the  stanchion.  Ex- 
tension was  made  in  a  horizontal  line  by  the  pulleys  fastened  to  a 


414 


FRACTURES    OF    THE    FEMUR. 


Staple  at  one  end  of  the  rope,  and  by  the  noose  around  the  ankle  at 
the  other.  In  this  position,  with  or  without  anesthetics,  the  woollen 
cloth  having  been  first  neatly  stitched  around  the  thigh,  and  the  peri- 
neum well  protected  by  extra  padding,  the  plaster  of  Paris  dressings 


Extension  continued  until  the  plaster  is  hard. 

were  applied,  extending  downwards  below  the  knee,  and  upwards  as 
high  as  the  ala3  of  the  pelvis.  Extension  was  not  relaxed  until  the 
dressings  hardened,  and  then  it  was  removed  altogether. 

It  may  be  remarked  that  if  the  employment  of  an<»sthetics  and  of 
the  pulleys  during  the  setting  and  dressing  of  the  fractures  shall  be 
found  useful  or  advantageous,  the  same  methods  may  be  applied  with 
equal  advantage  to.  other  permanent  dressings,  and  to  my  own  as  well 
as  to  any.  I  propose  to  make  the  trial  in  cases  which  may  hereafter 
com^  under  my  care. 

Finally,  having  considered  somewhat  at  length  the  leading  plans 
of  treatment  which  have  from  time  to  time  been  suggested  and  em- 
ployed b}^  our  best  surgeons  both  at  home  and  abroad,  I  desire  to 
describe  in  greater  detail  those  methods  and  forms  of  apparatus  which 
my  own  experience  has  taught  me  to  prefer. 

As  to  posture,  my  opinions  are  in  accord  with  the  opinions  of  a 
vast  majority  of  the  most  experienced  "surgeons  of  the  present  day. 
The  straight  position  will,  on  the  average,  give  the  best  results. 
Careful  measurements  made  by  myself  in  several  hundreds  of  cases,  a 
portion  of  which  have  been  published  in  my  statistical  tables,'  have 
demonstrated  that  the  average  shortening  of  the  limb  is  greater  after 
any  method  of  treatment  in  which  the  flexed  position  is  employed, 
than  after  treatment  with  extension  in  the  straight  position.  These 
observations  have  also  shown  that  the  flexed  position,  contrary  to  the 
reiterated  statements  of  its  advocates,  is  more  apt  to  entail  angular 
deformity. 

There  are  a  few  who,  rejecting  the  flexed  position  in  fractures  of 

>  Fracture  Tables,  by  F.  II.  Hamilton,  1853. 


FRACTUEES  OF  THE  SHAFT  OF  THE  FEMUR. 


415 


the  middle  of  the  shaft,  still  declare  for  this  position  a  preference 
when  the  fracture  occurs  just  below  the  trochanters,  and  in  the  case 
of  fractures  at  the  base  of  the  condyles. 

According  to  Malgaigne,  who  has  devoted  especial  study  to  this 
subject,  there  is  no  satisfactory  evidence  in  favor  of  the  flexed  posi- 
tion when  the  fracture  occurs  below  the  trochanters.  It  is  not 
directly  forwards,  but  forwards  and  out- 
wards, that  the  lower  end  of  the  upper 
fragment  is  carried  by  the  action  of  the 
psoas magnus and  iliacusinternus;  sothat 
in  order  to  meet  the  supposed  indication 
it  would  be  necessary  to  carry  the  lower 
part  of  the  limb  outwards  also,  a  posi- 
tion which  would  certainly  be  found 
inconvenient,  if  not  actually  impracti- 
cable, in  the  majority  of  cases.  Nor 
can  the  tendency  of  the  upper  frag- 
ment to  advance  in  the  forward  direc- 
tion, and  consequently  to  separate  from 
the  lower,  be  met  efi'ectually  by  posture 
alone,  unless  the  thigh  is  completely 
flexed  upon  the  body.  Indeed,  it  is  ap- 
parent that  the  position  of  moderate 
flexion  will  rather  favor  the  action  of 
those  muscles  which  are  supposed  to  be 
chiefly  responsible  for  the  displacement. 
When  the  thigh  is  extended  upon  the 
body,  the  psoas  magnus  and  iliacus 
internus  are  acting  in  the  direction  of, 
and  parallel  to,  the  axis  of  the  femur, 
and  consequently  to  a  disadvantage  ;  but 
Avhen  the  limb  is  lifted,  their  action  is  more,  nearly  at  a  right  angle 
with  the  shaft,  and  their  ability  to  displace  the  fragment  is  greatly 
increased. 

Moreover,  it  ought  to  be  understood  that  broken  bones  are  seldom  or 
never  displaced  or  separated,  in  the  same  manner  they  would  be  if  they 
were  not  surrounded  with  many  other  structures  which  have  suffered 
little  or  no  disruption:  they  pass  each  other,  but  do  not  separate 
widely,  being  held  together  by  shreds  of  periosteum,  muscles,  tendons, 
ligaments,  &c.  The  same  happens  when  this  bone  is  broken  just  below 
the  trochanters;  the  upper  fragment  lies  always,  or  almost  always,  in 
immediate  contact  with  the  lower,  and  whatever  force  is  brought  to 
bear  upon  the  lower  fragment  more  or  less  directly  influences  the 
upper;  we  can  then  by  extension,  applied  to  the  leg,  draw  down  not 
only  the  lower  fragment,  but  we  can  drag  into  line  the  upper  fragment. 
No  doubt  in  this  attempt  we  shall  meet  with  some  resistance  from  the 
muscles  above  named ;  but  experience  has  always  shown  that  even 
moderate  extension,  applied  steadily  and  without  interruption,  seldom 
or  never  fails  to  overcome  the  resistance  of  the  most  powerful  muscles. 
We  constantly  avail  ourselves  of  this  principle  in  overcoming  the  ab- 


Fractnre  of  femur  just  below  trochan- 
ter minor. 


416 


FRACTURES    OF    THE    FEMUR. 


normal  contraction  of  muscles  in  connection  with  diseased  joints,  in 
the  reduction  of  old  dislocations,  and  in  many  other  ways. 

Whatever  the  advocates  of  flexion  in  fractures  of  the  femur  may 
say  to  the  contrary,  they  are  never  able  in  this  position  to  employ 
extension  and  counter-extension.  A  careful  examination  of  all  the 
double-inclined  planes  which  have  been  brought  under  my  notice, 
including  Nathan  R.  Smith's  and  Dr.  Hodgen's  suspending  apparatus, 
will  convince  any  experienced  observer  that  such  is  the  fact.  What- 
ever other  excellences  they  may  ])ossess,  this  does  not  belong  to  them. 
But  extension  is,  of  all  the  indications  of  treatment,  that  which  is  of 
the  greatest  importance  in  nearly  all  fiactures  of  the  thigh,  and  no 
less  important  in  the  upper  third  than  in  the  lower.  In  fact,  the  higher 
"we  ascend  in  the  limb,  the  greater  is  the  tendency  to  shorten,  as  my 
measurements  have  shown,  in  consequence  of  the  action  of  those 
powerful  muscles  which,  arising  above,  have  their  insertions  into  the 
lower  fragment. 

In  the  case  of  all  those  double-inclined  planes  where  the  body  rests 
upon  a  bed,  there  can  be  no  counter-extension  except  the  weight  of 
the  pelvis  and  its  contents.  It  will  not  do  to  fasten  the  pelvis  to  the 
bed  by  bands,  as  every  one  who  made  the  experiment  would  soon 
learn  ;  nor  will  the  groin  tolerate  the  pressure  of  counter-extending 
splints,  or  bands.  These  things  have  been  tried  in  a  thousand  ways, 
and  abandoned.  The  weight  of  the  pelvis  alone,  not  of  the  entire  body, 
is  the  only  counter-extending  force  which  can  be  made  available,  and 
this  is  wholly  insufficient.  In  Kathan  R.Smith's  anterior  suspension 
splint,  not  even  the  weight  of  the  pelvis  is  employed  as  a  means  of 
counter-extension,  the  pelvis  being  secured  to  the  splint  by  rollers, 
equally  with  the  thigh  and  leg. 

After  all,  I  prefer  to  leave  this  question  to  the  verdict  of  experience, 
and  happily  this  seems  to  be  conclusive,  if  we  may  accept  the  almost 
unanimous  testimony  of  those  surgeons  who  have  enjoyed  the  largest 
hospital  practice.  In  my  own  experience  the  ordinary  double- 
inclined  planes  have  constantly  given  the  worst  results,  both  in  regard 
to  length,  and  lateral  displacement;  they  are  the  most  difficult  to 
manage,  and  are  the  most  fatiguing  to  the  patients.  Nathan  R,  Smith's 
suspending  apparatus  permits  the  limb  to  shorten  more  than  the  pre- 
sent methods  of  extension;  and  it  afibrds  inadequate  support  along  the 
centre  of  the  shaft,  in  consecjuence  of  which  the  limb  is  apt  to  unite 
with  a  backward  curvature  or  angle.  In  some  gunshot  fractures 
treated  by  this  apparatus  this  posterior  curve  or  angle  has  been 
excessive. 

Even  the  old  methods  of  extension  were  preferable  to  flexion;  but 
they  had  always  two  serious  drawbacks.  First,  in  the  excoriations 
and  ulcerations  incident  to  the  application  of  extending  bands  or 
gaiters,  or  whatever  else  was  employed  lor  this  purpose.  Again  and 
again  I  have  seen  ulceration  of  the  instep,  of  the  integuments  above 
the  heel,  and  of  other  parts  of  the  foot  and  ankle,  from  extending 
bands;  and  second,  from  similar  excoriations,  ulcerations  and  deep 
sloughs  about  the  groin  and  perineum  caused  by  the  counter-extend- 
ing band.     It  is  true,  these  accidents  did  not  occur  often,  and  some- 


FRACTUEES  OF  THE  SHAFT  OF  THE  FEMUR.     417 

times  they  were  due  wholly  to  negligence ;  but  in  order  to  avoid 
them  we  were  compelled  to  limit  very  much  the  amount  of  extension, 
and  to  exercise  unceasing  vigilance.  Only  recently,  at  Bellevue,  an 
attempt  was  made  to  employ  counter-extension  in  the  perineum  of  an 
adult,  by  plaster  of  Paris  applied  in  the  usual  manner  for  a  broken 
femur,  and  as  a  consequence  a  perineal  slough  was  soon  formed  two  or 
three  inches  in  depth  by  several  inches  in  length.  Lente,  the  Burges, 
myself,  and  others  sought  to  overcome  some  of  the  difficulties  of  the 
perineal  band  by  various  contrivances;  and  perhaps  in  some  measure 
we  have  been  successful,,  but  still  the  danger  of  ulceration  existed 
wherever  much  force  was  employed,  or  the  integuments  were  unusu- 
ally delicate.  Gilbert's  plan  of  substituting  adhesive  plasters  for  the 
usual  counter-extending  band,  and  Buck's  plan  of  employing  elastic 
tubing,  possess  no  real  advantages.  The  truth  is,  there  is  no  point 
about  the  groin,  perineum,  or  pelvis  upon  which,  by  one  surgeon  or 
another,  the  pressure  has  not  been  made,  and  more  or  less  distributed, 
and  there  is  no  method  perhaps  which  has  not  been  employed,  yet, 
after  a  fair  trial,  the  results  are  the  same.  The  pressure  must  be 
moderate,  or  serious  accidents  will  occasionally  happen.^ 

Hodge's  attempt  to  make  the  counter-extension  from  the  sides  of 
the  trunk  by  strips  of  adhesive  plaster,  as  already  described,  is  wholly 
inefficient  in  a  large  majority  of  cases. 

Our  first  great  step  of  progress  in  the  treatment  of  fractures  of  the 
thigh  consists,  then,  in  having  secured  counter-extension  by  the 
weight  of  the  body  alone,  and  this  is  accomplished  by  simply  ele- 
vating the  foot  of  the  bed  from  four  to  six  inches.  I  have  not  used 
a  perineal  band,  except  in  case  of  children,  for  eight  or  ten  years ; 
and  in  the  case  of  children  the  weight  of  the  body  is  still  my  chief 
reliance.  None  of  my  colleagues  at  Bellevue  use  the  perineal  band 
to-day. 

The  second  step  of  progress  was  the  introduction  of  the  method 
of  extension  by  adhesive  plasters,  weights,  and  pulleys,  without 
which  we  would  be  unable  to  employ  effectively  the  weight  of  the 
body  as  a  means  of  counter-extension,  and  by  the  use  of  which  all 
danger  of  excoriation,  ulceration,  and  sloughing  about  the  foot  is 
completely  avoided.  The  suggestion  of  adhesive  plaster  extension 
has  been  claimed  for  both  Dr.  Gross  and  Dr.  Wallace,  of  Philadelphia, 
and  for  Dr.  Swift,  of  Easton,  Pennsylvania;  but,  however  this  may  be, 
to  Dr.  Josiah  Crosby,  of  New  Hampshire,  is  certainly  due  the  credit 
of  having  brought  it  conspicuously  before  the  profession.^ 

As  to  the  bed  upon  which  the  patient  is  to  repose,  it  seems  proper 
to  say  that,  whenever  the  circumstances  of  the  patient  will  warrant 
the  expense,  a  bed  constructed  with  especial  view  to  fractures  of  the 
thigh  ought  to  be  regarded  as  an  essential  part  of  the  apparatus; 
always  contributing  to  the  comfort  of  the  patient,  if  it  is  not  absolutely 
necessary  to  the  attainment  of  the  most  complete  success.  Indeed, 
where  some  form  of  fracture-bed  cannot  be  procured,  or  extempora- 

1  For  cases  of  sloughinff,  ifec,  from  perineal  band,  see  N.  Y.  Joiirn.  of  Med., 
vol.  xiv.,  2d  ser.,  p.  261,  March,  ISoG  ;  also  same  journal.  Jan.  1840,  p.  239. 

2  New  Hampshire  Journ.  Med.,  1851  ;  Trans.  Amer.  Med.  Assoc,  vol.  iii.  p.  382. 


418 


FRACTURES    OF    THE    FEMUR. 


neoiisly  constructed,  and  the  patient  is  compelled  to  lie  upon  a  com- 
mon cot  bedstead,  or  a  common  post  bedstead,  or  upon  the  floor,  I 
cannot  think  the  surgeon  ought  to  be  held  in  any  degree  responsible 
for  the  result. 

The  fracture-beds  in  use  among  American  surgeons  are  exceedingly 
various,  among  which  I  will  mention,  as  being  especially  ingenious, 
the  beds  invented  by  Jenks,  Daniels,  the  Burges,  Addinell  Hewson, 
of  Philadelphia,'  J.  Ehea  Barton,  B.  H,  Coates,  of  the  same  city ,2  and 
J.  Crosby,  of  Manchester,  N.  H.^ 

Of  these  several  contrivances,  Jenks'  bed  (Fig.  168)  has  been  for  the 
longest  period  in  use  among  American  surgeons,  and  its  excellences 
most  thoroughly  tested.  It  is  composed  of  "two  upright  posts  about 
six  feet  high,  supported  each  by  a  pedestal ;  of  two  horizontal  bars  at 
the  top,  somewhat  longer  than  a  common  bedstead ;  of  a  windlass  of 

Fiff.  169. 


Jenks'  fracture-bed.     (From  Gibson.) 

the  same  length,  placed  six  inches  below  the  upper  bar ;  of  a  cog-wheel 
and  handle;  of  linen  belts,  from  six  to  twelve  inches  wide;  of  straps 
secured  at  one  end  to  the  windlass,  and  at  the  other  having  hooks 
attached  to  corresponding  eyes  in  the  linen  belts;  of  a  head-piece 
made  of  netting;  of  a  piece  of  sheet-iron  twelve  inches  long,  and  hol- 
lowed out  to  fit  and  surround  the  thigh  ;  of  a  bed-pan,  box  and  cushion 
to  support  it,  and  of  some  other  minor  parts. 

"  The  patient  lying  on  this  mattress,  and  his  limb  surrounded  by  the 
apparatus  of  Desault,  Hagedorn,  or  an}'-  other  that  may  be  preferred, 
the  surgeon,  or  any  common  attendant,  will  only  find  it  requisite  to 

'  Hewson,  Amer.  Journ.  Med.  Sci.,  July,  1858,  p.  101. 

2  Eclectic  Repertory,  5tli  and  9tli  vols. 

^  Crosby,  Treatise  on  Milit.  Surg.,  by  Frank  H.  Hamilton,  1865,  p.  413. 


FRACTURES  OF  THE  SHAFT  OF  THE  FEMUR. 


419 


pass  the  linen  belts  beneath  his  body  [attaching  them  to  the  hooks  on 
the  ends  of  the  straps,  and  adjusting  the  whole  at  the  proper  distance 
nnd  length,  so  as  to  balance  the  body  exactly],  and  raise  it  from  the 
mattress  by  turning  the  handle  of  the  windlass.  AVhile  thepatient  is 
thus  suspended,  the  bed  can  be  made  up,  and  the  fa3ces  and  urine  evacu- 
ated. To  lower  the  patient  again,  and  replace  him  on  the  mattress, 
the  windlass  must  be  reversed.  The  linen  belts  may  then  be  removed, 
and  the  body  brought  in  contact  with  the  sheets."^ 

But  in  my  own  experience  no  bed  has  proved  so  complete  and  uni- 
versally applicable  as  the  fracture-bed  invented  more  recently  by 
Daniels,  of  Owego,  New  York,  and  which  may  be  used  either  as  a 
double-inclined  plane  or  as  a  single  horizontal  plane  suitable  for  the 
support  of  the  patient  when  his  limb  is  dressed  with  the  straight 
splint. 


Fig.  170. 


E.  Daniels'  fracture-bed. 

Fiff.  171. 


'  Gibson's  Surgery,  vol.  i.  p.  330. 


420 


FEACTUEES    OF    THE    FEMUR. 


Fi£?.  172. 


E.  Daniels'  Fracture-Bed. 
"A  (Fig.  170)  represents  a  platform  of  suitable  length  and  width,  supported  hy  four  legs,  a.  To  the 
upper  surface  of  the  platform  is  attaclied  a  cross-piece,  b,  at  a  short  distance  from  the  centre,  and 
directly  through  the  centre  of  the  platform  Ig  made  a  circular  hole,  c  (in  dotted  lines),  said  hole 
having  a  semicircular  cut  or  recess  in  the  cross-piece  b.  To  the  straight  edge  of  the  cross-piece  b 
there  Is  attached,  by  hinges,  d,  a  board,  B,  termed  the  body  plane,  the  width  of  which  may  corre- 
spond with  that  of  the  platform  A,  and  when  depressed  its  outer  edge  may  be  even  with  the  edge  of 
the  platform.  The  sides  of  the  body  plane  may  be  elevated,  or  raised  ko  as  to  be  slightly  concave  on  its 
outer  surface.  To  the  opposite  side  or  edge  of  the  cross-piece  b,  and  at  each  side  of  the  semicircular  cut 
or  recess  formed  by  the  apertuie  c,  there  are  attached  by  hinges,  «,  cast-iron  plates,  C,  C,  which  are 
provided  with  grooves  or  ways  at  their  sides,  in  or  between  which  plates  D  D  work.  The  plates 
C  C,  D  D  (one  on  each  side)  are  thigh  plates,  and  their  edges  are  provided  with  projections,/,  in  which 
a  shaft,  g,  works,  one  on  each  plate  C.  On  each  shaft  ff  there  is  placed  a  pinion,  which  gears  into 
a  rack  attached  to  the  under  surface  of  the  plates  D  D.  At  one  end  of  the  shafts  g  are  attached  ratchets, 
g',  in  which  pawls, ./,  catch,  said  pawls  being  attached  to  the  sides  of  the  plates  C  C.  To  the  outer 
edges  of  the  plates  D  D  are  attached  by  hinges,  k,  boards,  E  E  ;  these  boards  are  leg  planes,  and  are 
slightly  raised  at  their  inner  ends,  where  they  are  connected  to  the  plates  Z),  in  order  to  form  depres- 
sions to  correspond  to  the  shape  of  the  legs.  To  the  under  surface  of  each  leg  plane  there  is  attached  a 
metal  guide,  I,  in  which  a  rack,  m,  works;  the  outer  ends  of  the  racks  have  bars,  n,  projecting  from 
them  at  right  angles.  To  each  leg  plane  is  attached  a  shaft,  o,  having  a  pinion,  p,  and  ratchet,  '/, 
thereon,  and  pawls,  r,  which  catch  into  the  ratchets  q,  the  pawls  being  attached  to  the  oute"  sides  of 
the  leg  planes.  The  pinions  gear  into  the  racks  to.  The  body  plane,  and  also  the  thigh  and  leg  planes, 
are  covered  by  a  suitable  mattress,  E,  with  a  hole  made  through  it  to  coi-respond  with  the  hole  in  the 
platform  A,  and  the  mattress  is  slit  or  cut  to  cover  properly  the  thigh  and  leg  planes  without  interfering 
with  their  movements.  To  the  under  side  of  the  platform  is  attached  by  hinges  a  flap,  F,  having  a 
stuflTed  pad  or  cushion,  t,  upon  it,  which,  when  the  flap  is  secured  upwards  against  the  platform,  fits  in 
the  hole  in  the  platform  and  mattress.     This  flap  is  secured  against  the  platform  by  a  button,  u." 

Sometimes  I  have  had  constructed  a  simple  frame,  covered  with  a 
stout  canvas  sacking,  having  a  hole  at  a  point  corresponding  with  the 
position  of  the  nates,  and  this  I  have  laid  directly  upon  a  common  four- 
post  bedstead.  A  mattress  an4  one  or  two  quilts  must  be  placed  upon 
the  boards  of  the  bedstead  underneath  the  sacking,  and  a  sheet  or  two 
above  the  sacking,  upon  which  last  the  patient  is  to  be  laid.  In  ar- 
ranging the  linen  underneath  the  patient,  the  most  convenient  plan  is, 
instead  of  using  only  one  sheet,  which  will  require  that  a  hole  shall 
be  made  in  it  corresponding  to  the  hole  in  the  sacking,  to  employ  two 
sheets,  and,  doubling  them  separately,  to  bring  the  folded  margin  of 
each  from  above  and  from  below  to  the  centre  of  the  opening.  When 
the  patient  has  occasioa  to  use  the  bed-pan,  it  is  only  necessary  that 


FRACTUEES  OF  THE  SHAFT  OF  THE  FEMUR. 


421 


two  or  four  persons  should  lift  this  frame,  and  place  under  each  corner 
a  block  about  one  foot  in  height,  or  it  may  be  raised  by  a  pulley  and 
ropes  suspended  from  the  ceiling. 

The  "invalid-bed,"  to  which  I  have  already  alluded  as  a  "fracture" 
bed,  invented  by  Dr.  Josiah  Crosby,  of  Manchester,  N.  H.,  and  which 
was  introduced  into  many  of  the  U.  S.  general  hospitals  by  order  of 
the  Surgeon-General,  has  been  found  to  be  of  great  service,  not  only 
in  the  management  of  invalids,  in  the  general  sense  of  that  term,  but 


Fia;.  173. 


Crosbv's  Invat.id-Bed,  closed. 

Fig.  174. 


Crosby's  Invalid-Bed,  open. 

The  bed  is  movable,  and  can  lie  run  out  from  under  the  patient  and  changed.     It  is  then  run  back, 

the  hooks  B  being  made  fast  to  the  catches  A.     By  turning  a  crank  at  C,  the  rail  D  is  revolved,  which 

winds  up  a  strap  passing  over  the  pulley  G,  and.  the  bed  is  raised  to  its  position,  thus  taking  oft"  the 

weiglit  of  the  patient  from  the  bands  by  which  he  was  temporarily  suspended. 

also  in  the  treatment  of  gunshot  fractures  of  the  thigh.     Indeed,  I 
have  hud  occasion  to  use  this  bedstead  in  Bellevue   Hospital,  and   I 
can  say  that  its  value  in  many  cases  can  scarcely  be  overestimated. 
We  may  also  floor  over  a  common  bedstead,  having  previously,  in 


422 


FEACTUEES    OF    THE    FEMUE. 


case  it  is  an  adult  whom  we  have  to  treat,  removed  the  foot-board,  so 
that  we  may  extend  the  floor  two  or  three  feet  beyond  the  usual  length 
of  the  bedstead.  In  the  centre  of  this  floor  we  may  make  an  opening, 
so  arranged  as  to  be  closed  by  a  board  slid  underneath,  or  by  a  door 
fastened  with  a  couple  of  leathern  hinges,  and  closed  by  a  spring 
catch. 

A  very  comfortable  bed,  especially  for  children,  can  sometimes  be 
made  from  a  cot.  But  it  will  be  necessary  always  to  nail  a  piece  of 
board  firmly  across  the  top  and  bottom  of  the  bedstead  when  the  sack- 
ing is  at  its  utmost  tension,  in  order  to  prevent  the  side  rails  from 
falling  together.  The  top  board  must  be  nailed  on  vertically,  like 
an  ordinary  head-board,  so  as  to  prevent  the  pillows  from  falling  off', 
but  the  bottom  piece  should  be  £tt  least  one  foot  wide,  and  laid  hori- 
zontally to  support  and  steady  the  apparatus  as  it  extends  beyond  the 
foot. 

Having  had  occasion  to  assist  the  late  Dr.  Treat  in  the  management 
of  a  fracture  of  the  thigh  in  the  case  of  a  little  girl  not  quite  three 
years  old,  I  was  struck  with  the  simplicity  and  completeness  of  an 
arrangement  which  he  had  made  to  prevent  the  bed  and  the  dressings 
from  becoming  soiled  with  the  urine.  It  was  only  to  leave  directly 
underneath  the  nates  a  complete  opening  through  to  the  floor  for  the 
escape  of  the  urine,  and  to  protect  the  margins  of  the  sacking  and 
sheets,  which  came  nearly  together  at  the  opening,  with  pieces  of  oiled 
cloth  folded  upon  themselves.  It  was  found  that  not  only  the  bed 
was  in  this  way  kept  dry,  but  the  dressings  also ;  it  being  now  ob- 
served that  the  dressings  had  become  wet  heretofore  by  soaking  up 
the  moisture  from  the  bed,  rather  than  by  the  direct  fall  of  the  urine 
upon  them. 

Having  prepared  the  bed  for  the  reception  of  the  patient,  and  ele- 
vated its  lower  end  about  four  inches  by  placing  blocks  underneath 
the  foot-posts,  the  following  additional  preparations 
should  be  made  before  we  proceed  to  reduce  the  frac- 
ture and  dress  the  limb  : — 

There  should  be  provided  a  piece  of  board  of  the 
requisite  length  and  breadth,  furnished  with  a  slot 
to  receive  the  pullej'',  and  called  the  "standard,"  a 
small  iron  rod,  a  pulley,  a  yard  of  rope,  and  a  vessel 
or  bag  to  receive  the  weights.  The  slot  should  have 
sufficient  length,  and  the  standard  should  be  perfo- 
rated in  the  direction  of  its  breadth  at  short  distances, 
to  enable  the  surgeon  to  elevate  or  depress  the  pulley, 
as  may  be  required.    In  case  a  tnetallic  pulley  cannot  be 

I  obtained,  a  spool  will  answer  as  a  tolerable  substitute. 

The  adhesive  plaster  which  I  have  generally  used 
both  in  private  and  hospital  practice  is  that  which  is 
usually  found  in  drug  stores,  spread  upon  linen ;  but 
some  of  my  colleagues  prefer  the  plaster  spread  upon 
jeans  or  canton-flannel,  as  being  stronger.  I  cannot, 
however,  appreciate  their  advantage,  since  the  ordinary 
standard.  plastcr  uevcr  gives  way. 


Fis.  175. 


FRACTUEES  OF  THE  SHAFT  OF  THE  FEMUR. 


423 


A  thin  block  or  piece  of  board,  called  tbe  "foot-piece,"  is  to  be  pro- 
vided, perforated  in  the  centre  to  receive  the  cord,  and  of  sufficient 
length  to  prevent  the  adhesive  strips  or  "extension  bands"  from 
pressing  upon  the  malleoli.  An  average  size  for  the  foot-piece  in  the 
case  of  an  adult  is  about  three  inches  and  three-quarters  in  length,  by 
two  and  a  half  in  breadth. 

The  adhesive  plaster  may  be  cut  in  the  shape  shown  in  the  illus- 
tration :  five  and  a  half  inches  wide  in  the  centre,  and  two  and  a  half 
inches  wide  at  the  narrowest  point, 

and  gradually  widening  again  to-  Fig.  176. 

ward  each  extremity  to  four  inches; 
the  narrower  portions  being  slit 
down  two-thirds  of  their  length. 
For  an  adult  we  generally  require 
a  strip  of  about  four  feet  and  eight 
inches  in  length,  namely,  sixteen 
inches  for  the  central  and  widest 
portion,  and  twenty  inches  for  each 

extremity.     The  shoulders  of  the  Foot-piece. 

central  portion  are  cut  as  repre- 
sented, in  order  that  when  folded  upon  the  foot-piece  and  upon  itself 
it  may  reinforce  the  lateral  bands  at  their  weakest  points. 


Fi£?.  177. 


Exteusion-'band  aud  foot-piece. 


Fi?.  178. 


Same,  folded  and  ready  for  use. 

The  lateral  or  side  splints  may  be  made  of  stout  leather,  cut  and 
moulded  to  the  limb,  or  of  thin  pieces  of  board  covered  with  cotton 
cloth,  and  stuffed  on  the  sides  next  to  the  skin  with  cotton  batting  to 
fit  all  the  inequalities  of  the  limb.  The  cotton  cloth  must  be  stitched 
over  the  splints  like  a  sac,  but  left  open  at  the  ends  until  the  padding 
is  properly  adjusted.  Loose  cotton  batting  always  becomes  displaced. 
Four  splints  are  generally  required :  one  for  the  anterior  surface, 
extending  from  the  groin  below  the  anterior  spines  of  the  pelvis  to 
within  half  an  inch  of  the  patella;  one  for  the  posterior  surface,  ex- 
tending from  the  tuberosity  of  the  ischium  to  a  point  two  inches 
below  the  knee ;  one  for  the  inside,  extending  from  near  the  perineum 
to  the  inner  condyle;  and  one  for  the  outside  extending  from  above 
the  trochanter  major  to  the  outer  condyle.  These  splints  ought  to 
encircle  the  limb  completely,  only  leaving  an  interval  of  from  half  an 
inch  to  one  inch  between  each  of  the  adjacent  splints.     The  outer  and 


424 


FRACTURES    OF    THE    FEMUR, 


inner  splints  may  be  extended  below  the  knee  when  the  fracture  is 
low  down;  but  in  that  case  they  must  be  carefully  fitted  to  the  ir- 
regularities of  the  condyles.  The  posterior  splint  is  the  most  impor- 
tant of  them  all.  It  should  be  wider  and  longer  than  either  of  the 
other  splints,  and  it  must  be  fitted  with  great  accuracy  to  the  back  of 
the  thigh,  ham,  and  upper  part  of  the  leg.  It  is  important  also  to 
cover  this  with  a  sac  of  cotton  cloth  so  that  it  may  be  stitched  to  the 
centre  of  the  bands,  which  are  to  inclose  all  the  splints.  If  this  is 
not  done,  it  is  very  liable  to  become  displaced. 

A  long  side  splint  must  now  be  prepared,  long  enough  to  extend 
from  about  four  inches  below  the  axilla  to  five  inches  below  the  heel ; 
four  and  a  half  inches  wide,  by  half  an  inch  in  thickness,  and  provided 
with  a  cross-piece  at  the  lower  end,  two  feet  long  by  three  inches  wide 
and  half  an  inch  thick.  The  purpose  of  this  splint  is  not  to  make 
extension  or  to  serve  as  a  side  coaptation  splint,  but  solely  to  prevent 
eversion  of  the  foot,  which  purpose  is  never  accomplished  effectively 
by  junks  or  by  any  other  method  I  have  yet  seen  adopted.  It  is  to 
be  employed  in  all  fractures  of  the  thigh,  including  fractures  of  the 
neck.  The  inner  surface  of  this  long  splint  must  be  padded  through 
its  whole  length,  and  thus  fitted  accurately  to  the  sides  of  the  body 
and  limb. 

Four  or  six  strips  of  cotton  cloth,  each  two  inches  wide  by  one 
yard  in  length,  are  now  stitched  by  their  centres  to  the  outer  surface 
of  the  long  back  splint,  and  these  are  laid  upon  the  bed  in  position 
for  the  splint  to  receive  the  limb. 

Fi?.  179. 


Mode  of  applying  adhesive  plaster. 


Supplied  with  rollers,  several  additional  strips  of  bandage,  and 
cotton-batting,  we  are  now  ready  to  reduce  and  dress  the  fracture. 
The  patient  being   placed  in  position  upon  the  bed,  one  assistant 


FEACTURES  OF  THE  SHAFT  OF  THE  FEMUR. 


425 


seizes  the  limb  by  the  knee,  and  a  second  by  the  foot,  drawing  upon 
it  firmly  and  steadily,  while  the  surgeon  lays  the  extremities  of  the 
extension  strips  upon  each  side  of  the  leg,  with  the  centre,  containing 
the  foot-piece  and  the  rope,  about  one  inch  below  the  sole  of  the  foot. 
With  a  muslin  roller,  inclosing  the  limb  from  near  the  metatarso-pha- 
langeal  articulation  to  the  tuberosity  of  the  tibia,  the  adhesive  strips 
are  held  in  place.  As  a  rule,  and  especially  in  the  case  of  women,  and 
of  persons  of  a  delicate  lax  fibre,  it  is  well  to  lay  against  the  tendo 
Achillis,  and  over  the  instep,  a  little  cotton  batting  before  applying  the 
roller.  In  some  cases  I  am  in  the  habit  of  applying,  a  thin  sheet  of 
cotton  wadding  over  the  whole  surface  of  the  limb.  Any  excess  of 
the  bands  at  the  upper  end  are  disposed  of  by  turning  them  down, 
and  inclosing  them  in  a  few  additional  turns  of  the  roller.  As  soon  as 
the  application  of  the  adhesive  strips  is  completed  the  weight  may  be 
adjusted,  and  extension  applied.  The  amount  of  extension  required 
for  adults  will  vary  from  eighteen  to  twenty-three  pounds.  In  a 
large  proportion  of  cases  twenty  or  twenty-one  pounds  will  be  borne 
without  complaint ;  and  the  ability  of  the  patient  to  tolerate  the  ex- 
tension, alone  limits  the  amount.  Occasionally,  even  a  few  pounds, 
when  first  applied,  causes  pain  in  the  ligaments  about  the  knee-joint ; 
but  in  a  few  hours  the  amount  may  be  increased.  It  is  better  to 
apply  eighteen  or  twenty  pounds  at  once,  if  it  can  be  borne.  Lifting  the 
knee  slightly  by  a  pad  placed  underneath,  will  often  relieve  the  pain 
caused  by  the  extension. 

Sometimes,  in  the  case  of  very  muscular  patients,  and  where  the 
primary  shortening  is  considerable,  I  believe  we  make  a  positive  and 
permanent  gain  if  we  place  the  patient  under  the  influence  of  chlo- 
roform for  a  few  minutes,  when  the  weight  is  first  applied.  In  these 
cases,  as  in  dislocations,  I  generally  prefer  chloroform  to  ether,  for  the 
reason  that  the  patient  is  less  liable  to  muscular  contractions  when 
he  is  passing  under  the  influence  of  the  anaesthetic. 


Fio-.  180. 


Author's  dressings  for  fracture  of  shaft  of  femur,  complete. 

Extension  being  effected,  and  the  patient  already  resting  upon  the 
posterior  coaptation  splint,  the  three  other  side  splints  are  applied, 
and  the  whole  secured  in  place  by  the  four  or  six  transverse  bands 
already  described  as  attached  to  the  posterior  splint ;  the  bands  being 
tied  over  the  front  splint  firmly. 
28 


426  FRACTUEES    OF    THE    FEMUR. 

It  remains  only  to  lay  the  long  splint  beside  the  body,  and  to  secure 
it  in  place  by  a  few  separate  strips  of  bandage. 

From  this  time  onward,  the  patient  should  be  seen  daily,  and  the 
coaptation  splints  loosened  or  tightened  from  time  to  time,  as  may  be 
required.  Ordinarily  it  is  not  necessary  to  disturb  the  extension  until 
the  union  is  completed.  The  usual  time  required  for  consolidation  in 
the  case  of  an  adult  is  from  six  to  eight  weeks  ;  but  if  the  bone  feels 
pretty  firm  at  the  end  of  four  weeks,  the  extension  may  be  a  little 
relaxed.  When  at  length  the  patient  is  permitted  to  leave  his  bed, 
a  pair  of  crutches  are  indispensable;  and  during  the  following  two 
months  but  little  weight  should  be  borne  upon  the  limb. 

Fractures  of  the  thigh  in  children  have  generally  been  found  more 
difficult  to  manage  than  fractures  of  the  same  bone  in  the  adult, 
owing  chiefly  to  the  shortness  of  the  limb,  the  delicacy  of  the  skin,  and 
the  restlessness  of  the  patient,  I  have  tried  nearly  all  forms  of  appa- 
ratus in  these  cases,  including  double-inclined  planes,  boxes,  single 
long  splints,  &c.,  and  the  result  of  my  experience  is  that  they  are  all 
inefficient;  and  for  some  years  I  have  employed  a  mode  of  dressing, 
partly  my  own  and  partly  the  suggestion  of  others,  but  of  which  I 
am  able  to  say  that  it  never  disappoints  me  in  the  result  obtained ; 
while  it  is  simple,  easy  of  management,  and  comfortable  to  the  little 
patients. 

Extension  by  means  of  adhesive  plaster  and  a  weight,  employed 
in  the  same  manner  as  in  adults,  constitutes  a  valuable  aid  in  most 
cases;  but  I  cannot  say  that  it  is  indispensable,  since,  with  children 
under  five  or  seven  years,  the  fractures  are  pretty  often  so  nearly 
transverse  that,  when  once  reduced  and  well  supported  by  lateral 
splints,  union  without  shortening  may  generally  be  expected ;  but  these 
results  become  less  and  less  frequent  as  we  advance  toward  adult 
life.  It  is  safe  and  proper,  according  to  my  experience,  to  employ  in 
any  case  extension,  somewhat  according  to  the  following  rule.  One 
pound  for  a  child  one  year  old,  two  for  a  child  two  years  old,  and  so 
on,  adding  one  pound  for  every  year  up  to  the  twentieth.  Of  much 
more  consequence,  however,  is  it  to  confine,  at  the  same  time,  both 
limbs,  for  as  long  as  one  is  at  liberty  it  is  almost  impossible  to  secure 
any  degree  of  quiet.  It  is  of  equal  importance,  in  my  opinion,  to 
give  to  the  limbs  an  extended  rather  than  a  flexed  position. 

My  plan  of  treatment,  therefore,  in  the  case  of  children,  is  in  all 
essential  respects  the  same  as  in  adults,  except  that  instead  of  one 
long  side  splint,  I  employ  two.  The  accompanying  illustrations  will 
explain  more  fully  my  meaning.  Two  long  side  splints  connected 
by  a  cross  piece  at  the  lower  ends,  and  reaching  upwards  to  near  the 
axillae,  separated  a  little  more  widely  below  than  above,  so  as  to 
render  the  perineum  more  accessible,  are  laid  upon  each  side  of  the 
body.  The  leg  of  the  broken  limb  is  secured  to  the  long  splint  with 
a  roller.  The  remainder  of  the  limb,  the  opposite  limb,  and  the  body, 
are  made  fast  with  broad  and  separate  strips  of  cloth.  The  coaptation 
splints,  in  the  case  of  children,  may  be  made  of  binder's  board. 

Thus  secured  and  laid  upon  a  bed,  such  as  I  have  already  described 
as  appropriate  for  children,  the  least  possible  annoyance  will  be  given 


FEACTURES  OF  THE  SHAFT  OF  THE  FEMUR. 


427 


to  the  surgeon.  The  dressings  are  but  little  liable  to  become  wet 
with  urine,  and  when  the  bed  is  soiled,  the  child  can  be  taken  up  with 
the  splint  and  carried  to  another;  indeed,  this  may  be  done  as  often 
as  the  patient  becomes  restless  or  weary,  without  any  risk  of  disturb- 
ing the  fracture. 


Fis:.  181. 


Fiii.  182. 


Author's  splint  for  fracture  of  the  femur  in 
children. 


Author's  dressing  for  fracture  of  the  femur  in 
children,  complete. 


In  case  the  surgeon  desires  to  use  extension  with  adhesive  plaster 
and  weights,  the  necessary  apparatus  may  be  made  fast  to  the  bed- 
stead, and  taken  off"  when  the  child  is  moved;  or  it  may,  if  thought 
best,  be  made  fast  to  the  foot-piece  of  the  splint. 

Occasionally,  with  children,  I  employ,  as  a  means  of  extra  safety,  a 
perineal  band,  drawn  moderately  tight,  and  fastened  to  the  top  of  the 
splint  on  the  side  corresponding  to  the  broken  limb.  The  best  peri- 
neal band  is  a  piece  of  soft  cotton  cloth,  one  or  two  yards  long,  by 
three  inches  wide,  folded  lengthwise,  to  a  flat  band  of  one  inch  in 
breadth,  and  inclosing,  where  it  passes  through  the  perineum  and 
under  the  nates,  a  few  thicknesses  of  paper.  The  paper  prevents  its 
drawing  into  a  round  cord.     Sometimes  I  place  between  the  paper 


428 


PRACTUEES    OF    THE    FEMUR. 


and  the  folded  cloth,  on  the  side  which  is  to  be  laid  next  to  the  skin, 
one  or  two  thicknesses  of  cotton  wadding.  To  absorb  the  moisture, 
it  is  well  to  lay  a  piece  of  sheet  lint  between  the  band  and  the  skin. 
The  perineal  band  may  be  removed  daily  and  renewed ;  and  the  peri- 
neum examined  and  washed. 

Four  or  five  weeks  is  generally  a  sufficient  length  of  time  for  per- 
fect consolidation,  in  children  under  five  years  of  age 

The  treatment  of  compound  fractures  of  the  thigh,  caused  by  gun- 
shot injuries,  will  be  considered  in  the  chapter  devoted  to  gunshot 
fractures.  Other  badly  comminuted  and  compound  fractures  of  this 
bone  are  to  be  managed  upon  the  same  general  principles  as  gunshot 
fractures. 

Those  compound  fractures  of  the  femur  which  have  been  caused 
by  the  thrusting  of  the  sharp  fragments  through  the  flesh,  and  in 
which  reduction  has  been  easily  effected,  have  in  most  cases  done  as 
well  as  simple  fractures,  except  that  the  limb  is  generall}''  a  little 
more  shortened.  The  wound  usually  soon  heals,  and  the  future  pro- 
gress of  the  case  is  the  same  as  that  of  a  simple  fracture.  They  may 
be  treated,  therefore,  in  the  same  manner  as  those  which  have  just 
been  described. 


§  5.  Fractures  of  the  Condyles. 
(a.)  Fractures  of  the  External  Condyle. 

Dr.  Alph  B.  Crosby,^  of  New  Hampshire,  has  published  an  account 
of  a  case  of  simple  fracture  of  the  external  condyle,  in  a  young  man 
twenty-one  years  of  age,  and  which  happened  from  a  sudden  twist  of 
the  limb,  while   he  was   undressing   himself  to 
Fig.  183.  bathe.     He  was  "  standing  on  a  shelving  bank, 

with  the  right  leg  flexed  over  the  left  in  order  to 
remove  his  pantaloons;  he  lost  his  balance,  par- 
tially twisted  the  leg,  and  fell  to  the  ground." 
Six  months  after,  the  fragment  was  removed  by 
Dr.  Crosby,  through  an  incision  below  the  con- 
dyle. The  recovery  of  the  young  man  has  been 
complete. 

The  accompanying  drawing  represents  the 
specimen  as  seen  from  its  lower  or  cartilaginous 
surface,  and  of  its  actual  size. 

Dr.  T.  S.  Kirkbride  has  also  reported  an  ex- 
ample of  simple  fracture  of  this  condyle,  which 
was  produced  by  the  kick  of  a  horse,  the  blow 
having  been  received  upon  the  inside  of  the  knee. 
When  this  patient  entered  the  Pennsylvania  Hospital,  Dec.  1834,  the 
knee  was  much  swollen,  and  crepitus  was  plainly  felt,  but  the  frag- 
ment was  not  displaced  ;  the  muscles  upon  the  outer  side,  however,  were 
so  strongly  contracted  as  to  abduct  the  leg,  and  produce  considerable 


Dr.  Crosby's  specimen  of 
fracture  of  the  external  con- 
dyle 


'  Ciosby,  New  Hampshire  Joiirn.  of  Med.,  1857. 


FRACTURES    OF    THE    CONDYLES. 


429 


Sir  Astley  Cooper's  case  of 
fracture  of  the  external  con- 
dyle. 


angular  deformity.  The  limb  could  be  easily- 
made  straight,  but  it  returned  to  its  former 
position  of  abduction  as  soon  as  it  was  released. 
When  fully  extended,  slight  bending  of  the 
joint  did  not  give  severe  pain  ;  but  when  in  any 
degree  flexed,  all  motion  was  very  painful. 

The  limb  was  placed  in  a  long  straight  frac- 
ture-box, and  cold  applications  were  made; 
great  swelling  followed.  It  was  kept  extended 
in  this  manner,  or  in  the  long  splint  of  De- 
sault,  twenty-eight  days;  at  which  time  union 
seemed  to  have  taken  place,  but  the  motions  at 
the  joints  were  very  limited,  and  productive  of 
great  pain.  From  this  period  the  limb  was 
laid  in  a  splint,  so  constructed  as  that  the  angle 
of  the  knee  could  be  changed  daily.  At  the 
end  of  about  six  weeks  he  began  to  walk  on 
crutches,  and  he  could  then  flex  the  leg  to  a 
right  angle.^ 

Sir  Astley  has  related  a  case  of  compound 
fracture  of  the  same  condyle,  produced  by  fall- 
ing from  a  curb-stone  upon  the  knees.  The  man  died  on  the  twenty- 
fourth  day.  On  examination  after  death,  the  external  condyle  was 
found  to  be  broken  oftj  and  also  a  considerable  fragment  was  detached 
from  the  shaft  higher  up.^ 

(b.)  Fractures  of  the  Internal  Condyle. 

Dr.  Thomas  Wells,  of  Columbia,  S.  C,  has  reported  an  example  of 
fracture  of  the  internal  cond3de,  accompanied  with  a  dislocation  of  the 
head  of  the  tibia  outwards  and  backwards.  The  man  was  about  forty 
years  old,  and  intemperate.  Dr.  Wells  was  not  called  until  two  days 
after  the  injury  was  received,  when  he  found  the  limb  greatly  swollen 
and  gangrenous.  The  man's  account  of  himself  was  that  while  walk- 
ing in  the  back  yard  he  fell,  and  thus  dislocated  his  knee,  and  that 
he  was  then  brought  into  the  house,  being  unable  to  stand  upon  his 
feet.  It  does  not  appear  that  any  attempt  was  made  to  reduce  the 
limb,  probably  because  his  general  condition  indicated  that  speedy 
death  was  inevitable.  On  the  fourth  day  he  died.  The  autopsy  dis- 
closed, in  addition  to  the  dislocation  of  the  tibia,  that  a  thick  scale  of 
bone  was  broken  from  the  inner  part  of  the  inner  condyle,  but  it 
remained  attached  to  the  ligaments.^ 

A  case  reported  to  me  by  Dr.  Lewis  Riggs,  a  very  intelligent  sur- 
geon, practising  in  Homer,  Oneida  Co.,  N.  Y.,  was  more  successful. 

A  lad,  set.  15,  was  kicked  by  a  horse,  the  blow  being  received  upon 
the  right  knee.  Dr.  Riggs  saw  him  within  three  hours  after  the  acci- 
dent, and  found  the  internal  condyle  of  the  right  femur  broken  off, 

•  Kirkbride,  Amer.  Jonrn.  Med.  Sci.,  May,  1885,  vol.  xvi.  p.  32. 

2  Sir  Astley  Cooper,  On  Disloc,  &c.,  op.  cit.,  p.  239. 

3  Wells,  Anier.  Jourii.  Med.  Sci.,  May,  1832,  vol.  x.  p.  25. 


430  FRACTUEES  OF  THE  FEMUR. 

carrying  away  more  than  half  the  articulating  surface  of  the  joint; 
the  tibia  and  fibula  were  at  the  same  time  dislocated  inwards  and 
upwards,  carrying  with  them  the  broken  condyle  and  the  patella.  The 
displacement  upwards  was  about  two  inches,  and  the  sharp  point  of 
the  inner  fragment  had  nearly  penetrated  the  skin.  There  was  no 
external  wound.  The  knee  presented  a  very  extraordinary  appear- 
ance, and  the  lad  was  suffering  greatly.  Being  at  a  distance  from 
town,  and  the  doctor  having  no  chloroform  or  pulleys  with  him,  he 
was  obliged  to  depend  solely  upon  the  aid  of  five  men  who  were  pre- 
sent. The  first  attempt  at  reduction  was  unsuccessful;  but  in  the 
second  attempt,  when  the  men  were  nearly  exhausted  in  their  efforts 
at  extension  and  counter-extension,  and  while  the  doctor  was  pressing 
forcibly  with  both  hands  upon  the  two  condyles,  the  bones  suddenly 
came  into  position,  except  that  the  breadth  of  the  knee  seemed  to  be 
slightly  greater  than  the  other,  a  circumstance  which  was  probably 
due  to  the  irregularities  of  the  broken  surfaces,  which  prevented  per- 
fect coaptation. 

Neither  splints  nor  bandages  were  required  to  maintain  the  bones 
in  place;  but  anticipating  the  probable  occurrence  of  anchylosis,  and 
with  a  view  to  making  "the  limb  as  useful  as  possible  in  this  condi- 
tion," he  was  placed  upon  "  a  double-inclined  plane,"  which  being 
supplied  with  lateral  supports,  would  also  prevent  any  deflection  in 
either  direction,  in  case  the  limb  was  disposed  to  such  displacement. 

The  subsequent  treatment  consisted  in  the  use  of  cold  water  dress- 
ings. Very  little  inflammation  followed.  A  portion  of  the  integu- 
ment sloughed,  but  the  bone  was  not  exposed,  and  it  healed  rapidly. 
On  the  twenty-fourth  day  Dr.  Riggs  gave  to  the  joint  passive  motion, 
and  this  was  repeated  at  intervals  until,  at  the  end  of  three  months, 
he  was  able  to  walk  with  a  cane.  At  the  end  of  a  year  Dr.  Riggs 
examined  the  leg,  and  found  the  knee  a  very  little  larger  than  the 
other,  and  he  could  not  flex  it  quite  as  completely.  In  all  other 
respects  it  was  perfect,  and  the  boy  himself  declared  it  was  as  good  as 
the  other. 

Treatment  of  Fractures  of  either  Condyle. — The  few  cases  of  these  acci- 
dents which  I  have  seen  reported  have  been,  with  one  or  two  exceptions, 
treated  in  the  straight  position.  In  Kirkbride's  case  any  degree  of 
flexion  was  painful,  although  there  was  little  or  no  displacement  of  the 
frac^ment;  and  we  think  we  can  see,  in  the  relative  position  of  the  arti- 
cular surfaces  of  the  tibia  and  femur,  a  sufficient  reason  why  the  straight 
or  nearly  straight  position  must  generally  be  preferred.  Whichever 
condyle  is  broken,  the  remaining  condyle  will  be  sufficient  to  prevent 
a  dislocation  and  consequent  shortening  of  the  limb,  unless,  indeed, 
the  dislocation  has  already  occurred  as  an  immediate  consequence  of 
the  injury.  It  is  very  certain  that  it  would  not  take  place  from  the 
action  of  the  muscles  when  the  limb  was  straight.  In  the  flexed  posi- 
tion I  can  conceive  that  it  might  take  ])lace,  but  yet  not  easily.  It  is 
not  a  dislocation  of  the  limb,  then,  that  we  seek  chiefly  to  avoid,  but 
a  deflection  of  the  leg  to  the  right  or  to  the  left,  according  as  one  or 
the  other  of  the  condyles  has  been  broken.  It  will  be  readily  seen 
that,  in  order  to  resist  this  tendency,  nothing  but  the  straight  position 


FRACTURES    OF    THE    CONDYLES.  431 

will  answer,  and  that  for  this  purpose  it  will  be  necessary  to  lay  a 
long  splint  upon  one  or  both  sides  of  the  limb,  and  to  secure  the 
whole  length  of  both  thigh  and  leg  to  this  splint.  The  long  fracture- 
box  used  by  Kirkbride,  if  well  cushioned  on  all  sides,  seems  to  me  at 
once  to  answer  most  completely  this  important  indication,  rendering 
it  even  unnecessary  to  employ  a  bandage,  since  the  opposite  sides  of 
the  box  will  compel  the  limb  to  adopt  the  proper  position. 

As  to  the  remainder  of  the  treatment,  it  must  consist  essentially  in 
the  active  employment  of  such  means  as  are  calculated  to  prevent  and 
allav  inflammation;  especially  ought  the  surgeon  not  to  omit  to  avail 
himself  of  so  valuable  an  antiphlogistic  agent  as  cool  water  lotions. 

As  soon  as  the  union  is  consummated  the  joint  surfaces  should  be 
submitted  to  passive  motion,  in  order  to  prevent  anchylosis;  and  it 
would  be  better  to  commence  this  so  early  as  to  hazard  somewhat  a 
displacement  of  the  fragment,  rather  than  to  wait  too  long.  It  may 
not,  in  some  cases,  be  improper  as  early  as  the  fourteenth  day,  and  in 
nearly  all  cases  it  should  be  practised  as  early  as  the  twenty -eighth. 

(c.)  Fractures  betiveen  the  Condyles  and  across  the  Base. 

Etiology. — A  fracture  of  this  character  may  be  produced  by  a  blow 
received  upon  the  side  of  the  limb  or  upon  the  lower  extremity  of  the 
femur;  sometimes  the  blow  has  been  received  directly  upon  the  patella 
when  the  knee  was  bent,  and  Bichat  mentions  a  case  in  which  it  was 
produced  by  a  fall  upon  the  feet. 

Symptoms. — This  fracture  is  easily  distinguished  from  the  preceding 
by  the  much  greater  mobility  of  the  fragments  and  by  the  palpable 
shortening  of  the  limb,  since  an  overlapping  of  the  broken  end  is 
here  almost  inevitable.  Each  fragment  may  be  felt  to  move  separately, 
and  the  motion  will  be  accompanied  with  crepitus. 

Prognosis. — The  danger  of  violent  inflamtnation  in  the  joint  is  im- 
minent, and  anchylosis  of  the  knee  is  to  be  anticipated  as  the  most 
favorable  result,  since  the  joint  surfaces  are  likely  to  be  rendered  im- 
movable by  fibrinous  deposits  in  their  immediate  vicinity,  and  also 
by  the  adhesion  of  the  muscles  to  one  another  and  to  the  bone  higher 
up,  where  the  fracture  of  the  shaft  has  occurred.  More  fortunate 
results  than  these  may,  indeed,  be  hoped  for,  inasmuch  as  they  have 
occasionally  been  noticed,  but  they  cannot  fairly  be  expected. 

In  a  majority  of  cases,  such  accidents  have  demanded,  either  imme- 
diately or  at  a  later  period,  amputation.  If  recovery  takes  place,  a 
shortening  of  the  thigh  is  inevitable.  Mr.  Canton,  of  London,  has 
twice  performed  successfully  resection  of  the  joint  end  of  the  bone  in 
such  accidents.^ 

Treatment. — Malgaigne  saw  a  patient  who  had  been  treated  by 
Guerbois  with  the  aid  of  extension  and. counter-extension,  who  was 
confined  to  his  bed  five  months,  and  who  had  at  the  end  of  eight  years 
very  little  motion  in  the  joint,  and  he  seems  disposed  to  charge  in 
some  measure  these  unfortunate  consequences  to  the  position  in  which 

'  Lancet,  Aug.  28,  I808.     Trans.  Loudon  Path.  Soc,  18G0. 


432  FKACTUEES    OF    THE    FEMUE. 

the  limb  was  placed,  namely,  the  straight  position.  But,  in  my  opinion, 
it  is  much  more  reasonable  to  suppose  that,  if  the  treatment  was  at 
all  responsible  for  the  results,  the  error  consisted  in  too  long  and  un- 
necessary confinement,  and  in  too  much  extension.  I  suspect  that 
the  mere  matter  of  position  had  nothing  to  do  with  the  anchylosis. 
Malgaigne  does  not,  however,  himself  recommend  anything  more  than 
a  very  slight  amount  of  flexion  at  the  knee;  and  to  this  practice  I 
am  prepared  to  give  my  assent;  since  it  will  give  to  the  limb  a  useful 
position  in  case  anchylosis  does  occur,  and  it  is  not  inconsistent  with 
the  employment  of  the  moderate  amount  of  extension  which  alone  is 
justifiable  after  this  accident.  If  the  young  surgeon  should  differ 
with  me  in  opinion  as  to  the  necessity  or  propriety  of  using  greaj; 
force  to  retain  the  fragments  in  place  and  prevent  overlapping,  I  beg 
him  to  consider  that  this  fracture  probably  never  happens  except  from 
the  application  of  an  extraordinary  force,  and  that  consequently  intense 
inflammation  and  swelling  are  almost  certain  to  ensue;  and  that  in 
some  cases,  the  very  fact  that  immediately  after  the  accident,  or  for 
some  hours  succeeding,  no  swelling  occurs,  or  muscular  contraction, 
and  that  replacement  of  the  fragments  is  easily  accomplished,  is  evi- 
dence only  of  the  great  severity  of  the  injury,  and  that  the  whole 
system  is  lying  under  the  shock;  to  which,  if  the  patient  does  not 
succumb,  sooner  or  later  reaction  will  ensue,  and  the  fragments  will 
be  gradually  drawn  up  with  a  resistless  power.  The  surgeon  ought 
to  remember  also  that  to  make  extension  in  this  case,  he  is  obliged 
to  pull  upon  those  very  ligaments  and  tendons  about  the  joint  which, 
having  been  torn  or  bruised,  must  soon  become  exquisitely  sensitive. 

The  long  straight  box,  already  recommended  when  speaking  of 
fracture  of  one  condyle,  is  equally  applicable  here  ;  only  that  it  needs 
a  foot-board,  or  some  sort  of  foot-piece  to  which  an  extending  appa- 
ratus may  be  secured,  and  that  a  pillow  should  be  placed  under  the 
knee  to  give  the  limb  the  proper  flexion. 

Case. — A  man  was  admitted  into  St.  Thomas's  Hospital,  London, 
Sept.  17, 1816,  with  a  fracture  between  the  condyles,  accompanied  also 
with  a  fracture  through  the  shaft  higher  up,  occasioned  by  being 
caught  in  the  wheels  of  a  carriage  while  in  motion.  There  was  a 
small  wound  opposite  the  point  of  fracture,  and  the  external  condyle 
was  displaced  outwards. 

The  limb  was  laid  in  a  fracture-box,  and  in  a  position  of  semi- 
flexion. 

On  the  18th  of  November,  the  external  condyle,  having  protruded 
through  the  skin,  and  being  dead,  was  removed  with  the  forceps, 
bringing  with  it  a  portion  of  the  articular  surface. 

On  the  6th  of  December  he  was  discharged  from  the  hospital,  and 
in  February  following  he  was  walking  without  any  support,  and  with 
the  free  use  of  the  joint.^ 

Case. — A  gentleman  living  about  eighty  miles  from  town  was 
thrown  from  his  carriage,  breaking  the  left  femur  just  above  the  con- 
dyles into  many  fragments,  so  that  when  I  saw  him  on  the  following 

'  A.  Cooper  on  Disloc,  &c.,  op.  cit.,  p.  339. 


FEACTURES    OF    THE    CONDYLES.  483 

day,  the  attending  physician  showed  me  about  four  or  five  inches  of 
the  entire  thickness  of  the  shaft  which  he  had  removed.  The  external 
condyle  was  completely  separated  from  the  internal,  and  was  quite 
movable. 

In  this  case  the  attempt  to  save  the  limb  resulted  in  the  loss  of  the 
patient's  life  on  the  sixth  or  seventh  day, 

(d.)  Sejiaration  of  the  Loioer  Epiphysis. 

M.  Coural  relates  the  case  of  a  boy  11  years  old,  who,  while  his 
leg  was  buried  in  a  hole  up  to  his  knee,  fell  forwards,  separating  the 
lower  epiphysis  from  the  shaft,  and  at  the  same  time  driving  the  shaft 
behind  the  condyles  into  the  popliteal  space.  The  epiphysis  also 
became  tilted  in  such  a  manner  that  its  lower  extremity  was  directed 
forwards.     The  limb  was  amputated. 

Madame  Lachapelle  mentions  a  case  in  which  traction  at  the  foot  of 
a  child  in  the  act  of  birth  caused  at  the  same  time  a  separation  of  the 
lower  epiphysis  of  the  femur  and  the  upper  epiphysis  of  the  tibia. 
The  child  was  born  dead.^ 

Dr.  Little  presented  to  the  New  York  Pathological  Society,  May  24, 
1865,  a  specimen  obtained  from  his  own  practice.  A  boy,  £et.  11, 
"while  hanging  on  to  the  back  of  a  wagon,  had  his  right  leg  caught 
between  the  spokes  of  the  wheel  while  it  was  in  rapid  motion.  A  few 
hours  after  the  accident,  Dr.  Little  found  the  upper  fragment  of  the 
femur  projecting  through  an  opening  in  the  upper  and  outer  part  of 
the  popliteal  space.  On  examination,  the  wound  did  not  appear  to 
communicate  with  the  knee-joint.  Under  the  influence  of  an  anaes- 
thetic the  fragments  were  reduced ;  the  reduction  occasioning  a  dull 
cartilaginous  crepitus.  There  was  at  the  time  no  pulsation  in  the 
posterior  tibial  artery,  and  the  limb  was  cold.  The  limb  was  laid 
over  a  double-inclined  plane.  The  following  day  the  upper  fragment 
was  again  displaced,  and  it  was  found  that  it  could  only  be  kept  in 
place  by  extreme  flexion  of  the  leg.  This  position  was  therefore 
adopted  and  maintained;  considerable  traumatic  fever  followed,  with 
swelling,  and  on  the  thirteenth  day  a  secondary  hemorrhage  occurred 
from  the  anterior  tibial  artery  near  its  origin,  and  it  became  necessary 
to  amputate.  The  boy  made  a  good  recovery.  The  specimen  showed 
that  the  line  of  separation  had  not  followed  the  cartilage  throughout, 
but  had  at  one  point  traversed  the  bony  structure. 

Dr.  Voss  at  the  same  meeting  remarked  that  he  had  met  with  the 
same  accident.  There  was  no  protrusion  of  bone,  but  an  abscess 
formed,  and  it  became  necessary  to  amputate. 

Dr.  Buck  saw  a  case  which  occurred  in  the  practice  of  Dr.  Hugh 
Walsh,  of  Fordham.  The  subject  was  a  boy  14  years  old,  and  it  hap- 
pened in  the  same  manner  as  with  Dr.  Little's  patient.^  I  know  of 
no  other  cases  of  this  accident. 

'  ^Malgaigne,  op.  cit..  t.  i.  p.  69. 

2  Little,  Voss,  Buck,  N.Y.  Journ.  Med.,  Nov.  1865. 


434  FRACTURES    OF    THE    PATELLA. 


CHAPTER    XXIX. 

FRACTURES  OF  THE  PATELLA. 

Canses. — Of  twenty-nine  fractures  of  the  patella  which  have  been 
recorded  by  me,  twenty-seven  were  the  result  of  direct  blows  or  of 
falls  upon  the  knee.  In  the  remaining  examples  the  fracture  was  due 
solely  to  muscular  action ;  one,  a  sailor,  aged  about  thirty  years,  had 
caught  the  heel  of  his  boot  in  a  knot-hole  in  the  floor,  which  threw 
him  backwards,  and  in  the  effort  to  sustain  himself  the  patella  was 
broken  transversely.  Dr.  Kirkbride  has  reported  a  case  in  which  both 
patellae  were  broken  in  a  similar  manner,  but  at  different  periods.  The 
patient  was  a  girl,  set.  29,  who  was  admitted  into  the  Pennsylvania  Hos- 
pital, Oct.  16,  1833,  "In  falling  backwards,  and  making  an  effort  to 
save  herself,"  the  right  patella  had  been  fractured.  She  was  dismissed 
cured  on  the  2d  of  December,  and  on  the  20th  of  April  following  she 
■was  readmitted,  with  a  fracture  of  the  left  patella,  produced  in  the 
same  manner  as  before ;  but  in  her  effort  to  save  the  right  limb,  the 
left  received  all  the  strain,  and  the  patella  gave  way.'  Dr.  Kirkbride 
records  another  instance  of  fracture  from  muscular  exertion  in  a  man 
£et.  32,  who  attempted  to  jump  into  a  cart,  by  raising  his  body  with 
his  hands  resting  upon  the  bottom  of  the  vehicle;'  and  Dr.  Hay  ward, 
of  Boston,  saw  a  case  in  the  Massachusetts  General  Hospital,  in  a  man 
get.  67,  which  occurred  in  consequence  of  a  false  step  in  descending 
a  flight  of  stairs." 

Pathology. — All  the  fractures  produced  by  muscular  action  have 
been  found  to  be  transverse,  and  the  same  is  true  generally  of  fractures 

Fio;.  185.  Fig.  186. 


produced  by  direct  blows;  occasionally,  however,  we  meet  with  lon- 
gitudinal fractures,  or  with  fractures  more  or  less  oblique  and  com- 
minuted.    Twenty-three  of  the  fractures  seen  by  me  were  simple  and 

»  Kirkbride,  Amer.  Journ.  Med.  Sci.,  Aug.  1835,  vol.  xvi.  p.  330. 
2  Hay  ward,  Amer.  Journ.  Med.  Sci.,  vol.  xxx.,  from  New  Eng.  Quart.  .Journ., 
July,  1843. 


FRACTURES  OF  THE  PATELLA. 


435 


transverse,  two  were  simple  and  oblique,  two  were  comminuted,  and 
one  was  compound.  Dupuytren,  A.  Cooper,  and  others,  have  also 
mentioned  cases  of  longitudinal  fracture. 


Fiff.  187. 


Fiff.  188. 


I  have  seen  a  double  transverse  fracture,  or  a  fracture  of  both 
patellae,  in  a  man  aet.  22,  who  fell  from  a  third-story  window,  striking, 
he  says,  upon  hia  knees.  He  was  taken  to  the  Hospital  of  the  Sisters 
of  Charity,  in  Buffalo,  and,  after  a  few  weeks,  made  an  excellent 
recovery. 

Symptoms. — The  symptoms  which  characterize  a  transverse  fracture 
of  the  patella  are  sufficiently  diagnostic.  The  fragments  are  separated 
from  each  other,  the  superior  fragment 
being  drawn  upwards  more  or  less,  ac- 
cording to  the  power  and  activity  of  the 
muscles  or  the  degree  to  which  the  liga- 
mentous coverings  and  attachments  of  the 
patella  have  been  torn.  Seldom,  however, 
is  the  interval  of  separation  greater  than 
half  an  inch.  But  in  a  few  cases  the  vio- 
lent flexion  of  the  knee  has  been  known 
to  draw  the  upper  fragment  quite  three 
inches  from  the  lower.  By  passing  the 
finger  along  the  anterior  surface  of  the 
limb  with  a  moderate  degree  of  firmness, 
the  depression  between  the  fragments 
will  be  made  manifest. 

No  crepitus  can  be  expected  unless  the  fragments  remain  in  contact, 
a  condition  which  is  unusual.  The  patient  is  unable  to  stand,  and  es- 
pecially is  the  power  of  extending  the  leg  upon  the  thigh  completely 
lost.  Usually  a  good  deal  of  swelling  immediately  succeeds  the  acci- 
dent, and  after  a  time  the  skin  becomes  more  or  less  discolored  from 
effusions  of  blood.  If  the  fracture  is  longitudinal  or  oblique,  a  slight 
separation  is  usually  present,  but  not  always  very  easily  detected. 

Prognosis. — One  of  my  patients,  who  had  a  comminuted  fracture, 
with  other  serious  injuries,  died,  but  not  as  a  consequence  of  the  frac- 
ture. In  the  following  case  the  fragments  appear  never  to  have  united, 
although  the  patient  recovered  : — 


eparated   by  flexion   of 


436 


FEACTUR"ES  OF  THE  PATELLA. 


Fig.  189. 


John  Sharkie,  set.  24,  a  soldier  in  the  British  service,  while  serving 
in  the  East  Indies,  was  struck  on  the  right  knee  while  he  was  in  a 
sitting  posture,  with  his  leg  bent  under  him. 
— -^He  was  immediately  placed  under  the  charge  of  the  surgeon  of  the 
o9th  regiment  of  infantry.  During  the  first  eleven  days  no  splints  or 
bandages  were  applied,  on  account  of  the  severe  inflammation  and 
swelling.  A  compress  was  then  placed  over  both  fragments,  and 
they  were  bound  together  by  rollers,  &c.  The  whole  limb  was  sus- 
pended on  an  inclined  plane,  the  foot  being  made  fast  to  a  foot-board. 
This  treatment  was  continued  four  months.  When  the  bandages  were 
removed,  the  limb  was  badly  swollen,  and  immediately  the  upper 
fragment  was  drawn  up  toward  the  body.  Eighteen  months  elapsed 
before  he  could  walk,  even  with  the  aid  of  a  cane. 

March  27,  1855,  twenty-nine  years  after  the  injury  was  received,  he 
was  an  inmate  of  the  Buffalo  Hospital,  and  I  was  permitted  to  ex- 
amine his  knee  carefully. 

The  lower  fragment  is  not  displaced,  but  when  the  leg  is  straight 
upon  the  thigh  the  upper  fragment  lies  two  and  a  half  inches  from 

the  lower,  and  when  it  is  flexed  upon  the 
thigh  the  upper  fragment  is  removed 
five  inches  from  the  lower. 

There  is  no  ligament  or  other  bond  of 
union,  so  far  as  I  can  discover.  He  walks 
with  very  little  or  no  halt,  but  he  cannot 
walk  fast. 

At  my  Bellevue  Hospital  clinic,  Janu- 
ary 8,  1866,  I  presented  a  man,  set.  38, 
who  had  fractured  his  left  patella  trans- 
versely, four  years  before.  The  frag- 
ments had  united,  when  he  ruptured  the 
ligament  again  by  a  fall.  I  found  a  sepa- 
ration of  three  and  a  half  inches,  and  the 
patient  unable  to  walk  except  with  the 
aid  of  a  leather  splint. 

In  the  case  of  a  man,  set.  40,  the  liga- 
mentous union,  at  first  complete,  seems  to  have  subsequently  given 
way  in  part.  He  called  upon  me  for  advice  nine  weeks  after  the 
fracture  had  occurred.  The  patella  was  surrounded  with  bony  callus, 
so  that  it  was  considerably  wider  than  the  other.  The  fragments 
appeared  to  be  united  by  a  short  ligament,  except  on  the  inner  side, 
where  there  was  a  separation  or  rupture  of  the  ligament  to  the  extent 
of  one-quarter  of  an  inch.  The  patient  explained  this  by  saying 
that  the  splint  was  removed  at  the  end  of  four  weeks,  and  that  after 
a  week  more  he  began  to  walk,  but  that  he  almost  immediately  felt 
it  tear  or  give  way  on  the  inner  side. 

During  the  autumn  of  1865  I  examined  the  leg  of  Dr.  B.,  a  graduate 
of  Bellevue  Medical  College,  and  found  a  transverse  fracture  of  the 
right  patella  with  great  displacement  of  the  upper  fragment.  He  in- 
formed me  that  he  had  fallen  six  years  before,  when  nineteen  years 
old,  upon  a  stone,  striking  upon  the  patella.     The  fracture  was  recog- 


FRACTUEES  OF  THE  PATELLA.  437 

nized,  and  the  limb  was  laid  upon  a  straight  splint.  At  the  end  of 
three  months  the  limb  was  removed  from  the  splint,  and  the  union  was 
found  to  be  complete,  with  a  separation  of  the  fragments  to  the  extent 
of  half  or  three-quarters  of  an  inch.  The  knee  was  much  anchylosed. 
Soon  after  this  the  upper  fragment  began  to  draw  up,  and  at  the  end  of 
a  year  was  as  much  displaced  as  it  is  now.  At  this  moment  it  is  dis- 
placed three  inches,  and  seems  to  be  held  to  the  lower  fragment  only 
by  a  narrow  ligament  attached  to  their  inner  margins.  He  extends 
and  flexes  the  leg  perfectly,  and  walks  without  the  least  halt,  but  this 
limb  wearies  sooner  than  tbe  other. 

February  16,  1866,  John  Donahue,  get.  50,  was  admitted  into  my 
wards  at  Bellevue,  with  a  refracture  of  the  right  patella.  He  stated 
that  it  was  first  broken  eight  weeks  before,  and  that  it  had  united,  bat 
that  the  day  before  his  admission,  while  seated  on  the  ground,  he 
attempted  to  rise,  and  that  the  ligament  suddenly  gave.  I  found  the 
fragments  separated  one  inch,  and  by  pressing  the  upper  fragment 
against  the  lower  a  slight  crepitus  was  occasioned.  His  limb  was 
placed  upon  a  single-inclined  plane,  and  union  soon  occurred. 

Dr.  Kirkbride  has  reported  a  case  of  ligamentous  union  of  the 
patella,  in  which  the  ligament  was  two  and  a  half  inches  long,  and 
was  attached  only  to  the  inner  margins  of  the  fracture.  "He  was  able 
to  walk  as  rapidly  as  ever,  and  without  perceptible  limping,"^  A 
similar  case  is  reported  by  Dr.  Watson,  of  New  York,  in  which  the 
fragments  became  separated  three  and  a  half  inches,^  In  both  instances 
the  fragments  were  supposed  to  have  united  by  a  short  ligament, 
which  had  become  lengthened  by  premature  use  of  the  limb;  in  the 
case  reported  by  Kirkbride,  the  ligament  seemed  to  have  partly  torn, 
as  in  the  case  reported  by  myself.  Dr.  Coale  presented  to  the  Boston 
Society  for  Medical  Improvement,  at  its  April  meeting  in  1856,  a 
specimen  of  a  fractured  patella  taken  from  a  man  sixty-five  years  old, 
the  fracture  having  occurred  ten  years  before.  The  fragments  were 
at  first  so  closely  united  that  no  division  between  them  could  be  dis- 
covered, but  subsequently  they  became  separated  at  their  outer  edges 
one  inch,  and  at  their  inner  edges  one-eighth  of  an  inch.^ 

I  have  seen  one  more  case  in  a  woman  at  Bellevue  Hospital,  who 
was  laboring  under  tertiary  lues  at  the  time  of  the  original  accident. 
She  says  the  bone  never  united,  and  at  this  time  the  fragments  are 
separated  about  three  inches.  She  can  only  walk  with  the  aid  of  a 
splint. 

In  every  instance  in  which  a  fracture  of  the  patella  has  been  treated 
by  myself,  union  has  taken  place  at  periods  varying  from  twenty- 
four  to  fifty-eight  days,  the  average  being  about  thirty-eight  days. 
Twenty-one  cases  have  united  by  ligaments,  varying  in  length  from 
one-quarter  to  one-half  an  inch.  These  measurements,  made  upon 
the  living  subject,  may  not  be  mathematically  accurate,  but  they 
cannot  be  far  from  the  truth.  In  no  case  has  the  function  of  the 
limb  been  in  any  degree  impaired  by  this  ligamentous  union;  from 

•  Kirkbride,  Amer.  Journ.  of  Med.  Sciences,  vol.  xvi.  p.  32. 

2  Watson,  N.  Y.  Journ.  of  Med.  and  Surgery,  vol.  iii.,  first  scries,  p.  3G6. 

3  Coale,  Boston  Med.  and  Surg.  Journal,  vol.  liv.  p.  402. 


438  FRACTUEES    OF    THE    PATELLA. 

wbicli  it  must  be  inferred  that  a  short  ligamentous  union  is  as  useful 
as  a  bony  union.     Practically  speaking,  my  results  have  been  perfect. 

Twice,  I  believe,  I  have  seen  a  bony  union  of  the  patella.  The  first 
instance  is  that  to  which  I  have  already  referred  as  an  oblique  or 
longitudinal  fracture  across  one  corner  of  the  patella;  and  in  the  other 
example  the  action  of  the  muscles  upon  the  upper  fragment  was  pre- 
vented by  the  occurrence  of  a  fracture  of  the  shaft  of  the  femur  at  the 
same  time,  which  permitted  the  thigh  to  shorten  upon  itself.  The 
man  was  about  twenty-five  years  old,  and  in  a  fall  from  a  scaffold  had 
broken  his  left  femur,  and  also  the  patella.  The  patella  was  broken 
transversely  near  its  middle,  and  also  longitudinally  near  its  inner 
margin.  The  fragments  were  all  distinctly  made  out.  Drs.  Lewis  and 
Dayton,  of  Buffalo,  were  in  attendance,  and  on  the  fifth  day  I  was 
called  in  consultation.  We  dressed  the  limb  with  a  long  straight 
splint,  employing  moderate  extension  and  counter-extension.  The 
patella  was  covered  with  strips  of  adhesive  plaster.  On  the  fifty- 
eighth  day  I  found  the  fragments  of  the  patella  united.  June  8, 1854, 
five  mouths  after  the  accident,  I  examined  the  limb  carefully.  The 
femur  was  shortened  half  an  inch,  and,  although  the  two  main  frag- 
ments of  the  patella  were  separated  half  an  inch,  the  bond  of  union 
seemed  to  be  bone.  It  was  hard,  and  allowed  of  no  motion  in  the 
upper  fragment  separate  from  the  lower.  The  lateral  fragment  was 
also  apparently  united  by  bone  and  in  place.  He  had  but  little  motion 
in  the  knee-joint,  yet  he  walked  very  well,  and  was  able  to  pursue  his 
trade,  as  a  carpenter,  without  much  inconvenience. 

Sir  Astley  Cooper  succeeded  in  obtaining  a  bony  union  in  some 
longitudinal  fractures,  but  in  a  majority  of  cases  it  failed,  owing  to  the 
want  of  apposition  in  the  fragments.  It  might  seem  that  it  would  be 
easy  to  accomplish  apposition  in  all  longitudinal  fractures,  but  expe- 
rience has  shown  that  it  is  not  always,  the  fragments  being  kept 
asunder  partly  by  the  action  of  the  oblique  fibres  of  the  vasti  and 
partly  by  the  pressure  of  the  condyles  of  the  femur,  especially  when 
the  leg  is  slightly  flexed. 

Whether  the  fracture  is  transverse  or  longitudinal,  a  bony  union 
may  occasionally  be  obtained  when  the  fragments  are  retained  in 
absolute  contact  for  a  sufficient  length  of  time ;  but  the  failure  to 
procure  a  bony  union  is  not  a  matter  of  consequence,  since  a  short 
ligament  is  equally  useful. 

Post,  of  New  York,  has  reported  three  cases  of  compound  fracture 
of  the  patella  extending  into  the  knee-joint,  brought  to  a  successful 
termination.^     I  have  myself  met  with  one  or  more  similar  results. 

In  a  case  mentioned  by  Eve,  of  Augusta,  occasioned  by  the  kick 
of  a  horse,  and  in  which  amputation  became  necessary  on  the  tenth 
day,  "  the  knee-joint  was  found  filled  with  dark  grumous  blood ;  a 
portion  of  the  cartilage  of  the  internal  condyle  of  the  os  femoris  was 
chipped  off,  and  the  patella  broken  into  a  number  of  fragments."^ 

Lewitt,  of  Michigan,  has  related  a  case  of  fracture  in  a  lad  set.  16, 

'  Post,  New  York  Jouru.  of  Med.,  vol.  ii.,  first  series,  p.  367. 
•2  Eve,  Southern  Med.  and  Surg.  Journ.,  1848  ;  also  Bost.  Med.  Journ.,  vol.  xxxvii. 
p.  427. 


FRACTURES  OF  THE  PATELLA.  439 

produced  by  striking  his  knee  against  a  piece  of  timber,  which  re- 
sulted in  suppuration  of  the  knee-joint,  but  from  which  he  finally 
recovered  with  the  perfect  use  of  the  limb.  The  fracture  of  the  patella 
was  oblique,  traversing  only  its  upper  and  outer  margin,  and  it  was 
never  much  displaced,' 

Dr.  Levergood,  of  Pennsylvania,  has  reported  a  similar  case,  in  which 
it  became  necessary  to  open  the  joint  freely,  yet  it  was  followed  by 
an  excellent  recovery,  only  a  slight  anchylosis  remaining  at  the  knee- 
joint.^ 

Treatment. — The  dressing  which  I  prefer  in  the  treatment  of  this 
fracture  consists  of  a  single  inclined  plane,  of  sufficient  length  to  sup- 
port the  thigh  and  leg,  and  about  six  inches  wider  than  the  limb  at 
the  knee.  This  plane  rises  from  a  horizontal  floor  of  the  same  length 
and  breadth,  and  is  supported  at  its  distal  end  by  an  upright  piece  of 
board,  which  serves  both  to  lift  the  plane  and  to  support  and  steady 
the  foot.  The  distal  end  of  the  inclined  plane  may  be  elevated  from 
six  to  twelve  inches,  according  to  the  length  of  the  limb  and  other 
circumstances.  Upon  either  side,  about  four  inches  below  the  knee, 
is  cut  a  deep  notch.  The  foot-piece  stands  at  right  angles  with  the 
inclined  plane,  and  not  at  right  angles  with  the  horizontal  floor. 

Having  covered  the  apparatus  with  a  thick  and  soft  cushion  care- 
fully adapted  to  all  the  irregularities  of  the  thigh  and  leg,  especial 
care  being  taken  to  fill  completely  the  space  under  the  knee,  the 
whole  limb  is  now  laid  upon  it,  and  the  foot  gently  secured  to  the 
foot-board,  between  which  and  the  foot  another  cushion  is  placed. 

The  body  of  the  patient  should  also  be  flexed  upon  the  thigh,  so  as 
the  more  efiectually  to  relax  the  quadriceps  femoris  muscle. 

Fiar.  190. 


The  author's  mode  of  dressing  a  fractured  patella. 

A  roller  is  now  applied  to  the  knee  by  oblique  and  circular  turns; 
commencing  above  the  patella,  and  traversing  the  notch  in  the  splint ; 
each  successive  turn  covering  more  of  the  front  of  the  knee  until  the 

'  Lewitt,  Medical  Independent,  Sept.  1856. 

2  Levergood,  Amer.  Journ.  Med.  Sci.,  Jan.  1800. 


440 


FRACTURES  OF  THE  PATELLA. 


whole  is  inclosed.  With  a  second  roller  the  entire  limb  must  then  be 
secured  to  the  splint,  this  roller  extending  from  the  ankle  to  the  groin. 

The  great  advantage  which  this  mode  of  dressing  possesses  is,  that 
it  does  not  ligate  the  leg  or  thigh  completely,  since,  on  either  side, 
between  the  broad  margins  of  the  splint  and  the  points  where  the 
bandages  touch  the  limb,  there  is  a  space,  more  or  less  considerable, 
against  which  no  pressure  is  made,  and  through  which  the  circulation 
may  go  on  without  impediment;  so  that,  however  firmly  the  bands 
are  drawn  across  the  knee,  no  swelling  occurs  in  the  foot. 

The  plan  adopted  by  M.  Gama,  of  Val  de  Grace,^  is  similar  to  that 
which  I  have  now  described,  but  the  splint  upon  which  the  limb 
reposes  is  not  so  wide,  while  width  is  an  essential  point  in  the  attain- 
ment of  the  objects  which  I  propose. 

The  dressing  and  apparatus  emplo^'ed  by  Wood,  of  King's  College 
Hospital,  are  very  similar  to  my  own,  but,  as  will  be  seen  by  the  accom- 
panying drawing,  the  splint  is  only  five  or  six  inches  wide.  Dr. 
Wood  has  substituted  hooks  for  the  notches.^ 


Fi.g.  191. 


Wood's  apparatus. 


Dr.  Dorsey,  of  Philadelphia,  employed  a  very  simple  apparatus 
which  will  serve  to  illustrate  the  general  plan  adopted  by  many  sur- 
geons, both  at  home  and  abroad.     It  is  liable,  however,  to  the  objec- 


Fi<r.  193. 


John  Syng  Doisey's  patella  splint. 


tion  already  stated,  namely,  that  it  interrupts  too  much  the  circula- 
tion of  the  limb.     His  apparatus  consists  of  a  piece  of  wood  half  an 

•  Malgaigne,  Traite  des  Fractures,  etc.,  op.  cit.,  p.  764. 
2  Ferjjusson's  Surgery,  p.  307. 


FRACTURES  OF  THE  PATELLA.  441 

inch  thick  and  two  or  three  inches  wide,  and  long  enough  to  extend 
from  the  buttock  to  the  heel;  near  the  middle  of  this  splint,  and  six 
inches  apart,  two  bands  of  strong  doubled  muslin,  a  yard  long,  are 
nailed.  The  splint  is  then  cushioned,  and  the  limb  laid  upon  it,  a 
roller  being  first  applied  from  the  ankle  to  the  groin,  encompassing 
the  knee  in  the  form  of  the  figure-of-8;  after  which  the  two  muslin 
bands  are  secured  across  the  knee  in  such  a  manner  as  that  the  lower 
one  shall  draw  down  the  upper  fragment,  and  the  upper  one  elevate 
the  lower  fragment. 

A  single  instance  will  explain  the  danger  of  ligation  to  which  I 
have  alluded,  and  which,  although  it  may  be  greater  in  case  a  starch 
or  dextrine  bandage  is  used,  exists  in  some  degree,  whatever  material 
for  bandaging  is  employed,  if  it  is  applied  to  the  whole  circumference 
of  the  limb,  and  constant  attention  is  not  paid  to  the  progress  of  the 
swelling. 

"A  vine-dresser,  set.  40,  of  a  good  constitution,  fell  and  received  a 
simple  transverse  fracture  of  the  patella  on  the  15th  of  January.  The 
medical  officer  called  upon  to  attend  him  applied  first  a  bandage  for 
the  purpose  of  drawing  together  the  fragments,  and  afterwards  a 
starched  l^ndage  extending  from  the  toes  to  the  upper  part  of  the 
thigh;  the  limb  was  then  put  upon  an  inclined  plane.  The  patient 
was  visited  a  few  times,  but,  as  he  scarcely  suffered,  the  apparatus 
was  in  no  way  disturbed.  On  the  first  of  March  (sixteenth  day)  the 
attendant  returned  to  remove  the  bandage,  when  the  odor  arising  from 
the  limb  led  him  to  believe  that  gangrene  had  taken  place,  and  Dr. 
Defer  was  sent  for.  Dr.  Defer  found  the  limb  in  the  following  state: 
The  toes,  which  were  not  covered  by  the  bandage,  were  completely 
insensible  and  mummified.  The  bandage  being  removed,  the  gan- 
grene was  perceived  to  extend  within  seven  inches  of  the  knee,  and 
was  arrested  in  its  progress.  The  foot  was  cold,  and  was  totally  in- 
sensible; the  epidermis  was  raised  up,  and  was  beginning  to  be  sepa- 
rated from  the  skin.  The  articulation  of  the  ankle  was  exposed,  and 
the  ligaments  destroyed.     The  bones  of  the  leg  were  also  exposed  in 

Fig.  193. 


Sir  A.  Cooper's  method  by  circular  tapes. 


their  lower  third,  and  the  tendons  were  in  a  sloughy  state.     Amputa- 
tion was  performed,  and  the  patient  recovered."^ 

Very  little  better  than  the  starch  bandage,  and  exposing  the  patient 

'  Amcr.  Journ.  Med.  Sci.,  vol.  xxiv.  p.  463,  from  Gazette  Medicalc,  No.  38. 

29 


442 


FRACTUEES  OF  THE  PATELLA. 


in  a  still  greater  degree  to  the  dangers  of  ligation  and  strangulation, 
are  either  of  the  methods  recommended  by  Sir  Astley  Cooper. 


Fig.  194. 


Sir  A.  Cooper's  method  by  a  leather  counter-strap. 


Mr.  Lonsdale's  instrument  is  ingenious,  but  complicated.     It  is  also 
liable  to  the  serious  objection  that  it  forbids  almost  entirely  the  use 


Fi?.  195. 


Lonsdale's  Apparatus  for  Fractured  Patella. — A  B.  Two  vertical  iron  bars,  each  supporting  a 
horizontal  one;  these  horizontal  arms  slide  upon  the  vertical  bars,  but  can  be  secured  at  any  point  by 
the  screws  C  D.  To  the  horizontal  beams  are  attached  other  vertical  rods,  which  are  movable,  and  yet 
fixable  by  screws,  as  at  E.  Finally,  to  each  of  these  last  upright  pieces  is  fixed  an  iron  plate,  F  F,  by 
means  of  a  hinge-joint,  which  keeps  the  patella  in  place.  The  foot-piece  is  movable  up  and  down  upou 
the  main  body  of  the  apparatus,  and  can  be  made  fast  at  any  point,  so  as  to  adapt  the  splint  to  limbs  of 
different  lengths. 

of  bandages,  which,  while  they  are  capable  of  doing  great  mischief 
when  they  bind  the  limb  too  closely,  are  capable  also  of  proving 
eminently  serviceable  when  they  press  upon  certain  portions  of  the 
limb,  and  not  with  too  much  force. 

Malgaigne's  hooks  or  clamps  I  regard  as  liable  to  more  serious 
objections,  and,  notwithstanding  considerable  testimony  in  their  favor, 
I  should  be  reluctant  to  recommend  them. 

For  the  same  reason  the  apparatus  invented  by  the  late  Dr.  Turner, 
of  Brooklyn,  N.  Y.,^  is  objectionable.  Moreover,  all  forms  of  appa- 
ratus which,  like  this  of  Dr.  Turner's,  are  secured  to  the  limb  by 
straps  with  intervals,  are  objectionable,  since  these  straps  do  not,  like 
'bandages,  give  uniform  support  to  the  surface  of  the  limb. 

Mr.  Hutchinson,  of  London,  has  of  late  omitted  to  elevate  the  foot 
in  the  treatment  of  this  fracture,  and  he  thinks  that  the  fragments  are 
maintained  in  apposition  with  quite  as  much  ease.^     I  cannot  agree 

•  Turner,  N.  Y.  Med.  Rec,  July,  1867. 

2  Hutchinson,  London  Hospital  Reports,  vol.  ii. 


FKACTURES  OF  THE  PATELLA. 


443 


Fis:.  196. 


with  him  that  nothing  is  ever  gained  by  the  eleva- 
tion of  the  foot.  On  the  contrary,  in  the  treatment 
of  a  certain  proportion  of  cases  this  position  will  be 
found  essential  to  the  best  success. 

I  have  recently  seen  in  use  at  the  Long  Island 
College  Hospital  a  very  ingenious  apparatus  devised 
by  Dr.  J.  H.  Hobart  Burge,  one  of  the  surgeons  of 
that  hospital.  The  fragments  being  approximated 
by  well-adjusted  sole-leather  pads,  which  are  ope 
rated  upon  by  weights,  cords,  and  pulleys.'^ 

Lausdale,  U.  S.  N.,  has  contrived  an  apparatus 
similar  to.that  invented  by  Burge,  but  more  simple.^ 

Gibson,  of  St.  Louis,  has  introduced,  in  a  modi- 
fied form,  the  circular  pad  or  ring,  first  devised  by 
Albucasis.^  Dr.  Eve,  of  Nashville,  and  Dr.  Black- 
man,  of  Cincinnati,  have  employed  this  method,  and 
speak  of  it  in  terms  of  high  commendation.^  I  can- 
not think,  however,  that  it  will  be  found  applicable 
to  any  large  number  of  cases,  and  especially  to  such 
cases  as  are  attended  with  much  contusion  and  swell- 
ing of  the  soft  parts. 

In  case  the  fracture  is  oblique  or  longitudinal,  it  will  only  be  neces- 
sary to  lay  the  limb  in  a  straight  position,  so  as  to  prevent  that  lateral 


Malgaigne's  hooks. 


Fiur.  197. 


Surge's  apparatus  for  fractured  patella. 

displacement  of  the  fragments  which  has  been  shown  to  occur  when 
the  limb  is  flexed.  It  will  not  be  necessary  to  employ  a  splint,  unless 
the  patient  is  unmanageable  and  demands  restraint,  nor  to  elevate  the 
foot.     After  the  swelling  has  subsided,  a  slight  amount  of  lateral 

'  Burge,  N.  Y.  Med.  Rec,  April  lo,  18G8,  p.  80. 

*  Lausdale,  Wales's  Surgery,  p.  476. 

3  Gibson,  Amer.  Journ.  Med.  Sci.,  Jan.  1867,  p.  281. 

*  Western  Journ.  Med.,  May,  1868.     Nashville  Journ.  Med.,  February,  1867. 


444 


FEACTURES    OF    THE    TIBIA. 


pressure,  accomplished  by  a  few  turns  of  a  roller,  with  or  without 
compresses,  as  the  circumstances  may  seem  to  demand,  will  complete 
the  mechanical  part  of  the  treatment. 


Fi-.  198. 


Lausdale's  apparatus. 


I  have  not  mentioned  the  rapid  and  sometimes  intense  inflammation 
to  which  the  knee-joint  is  liable  after  a  fracture  of  the  patella ;  and 
which  is  often  greatly  aggravated  by  the  injudicious  application  of 
bandages.  In  no  instance  ought  the  bandages  to  be  applied  very 
tightly  at  the  first  dressing;  and  during  the  first  five  or  six  days  the 
patient  ought  to  be  seen  once  or  twice  daily,  and  the  most  prompt 
attention  given  to  any  complaints  of  pain  or  soreness  about  the  knee. 

If  the  swelling  and  inflammation  increase  rapidly,  it  would  be  far 
better  to  remove  the  bandages  altogether  for  a  few  days,  than  to  take 
the  risks  consequent  upon  their  continuance. 

The  anchylosis  which  often  follows  the  recovery  of  the  patient,  and 
which  is  sometimes  almost  complete,  is  to  be  overcome  by  long-con- 
tinued passive  motion;  but  great  care  must  be  taken  not  to  rupture 
the  ligament,  as  we  have  already  seen  happen  in  some  cases. 

Dr.  Alfred  C.  Post,  of  the  New  York  Hospital,  has  excised  the 
knee-joint  in  a  case  of  anchylosis  of  long  standing;  the  limb  being 
so  much  flexed  in  consequence  of  a  comminuted  fracture  of  the  patella, 
as  to  be  not  merely  useless,  but  an  intolerable  encumbrance.  The 
patient  was  a  laboring  man  of  about  forty  years  of  age.  This  opera- 
tion was  made  in  preference  to  amputation,  at  the  request  of  the  man 
himself.^ 


CHAPTER   XXX. 

FRACTURES  OF  THE  TIBIA. 

Develo2:)ment  of  the  Tibia. — The  tibia  is  formed,  usually,  from  three 
centres  of  ossification — one  for  the  shaft,  and  one  for  either  extremity. 
Ossification  commences  in  the  shaft  at  about  the  filth  week  of  foetal 
life.     In  the  upper  epiphysis  it  appears  at  birth,  and  unites  with  the 

»  Post,  New  York  Med.  Gazette,  vol.  i.  p.  309,  Nov.  1850. 


FEACTUEES    OF    THE    TIBIA. 


Uo 


199. 


shaft  at  about  the  twenty-fifth  year.     Generally  it  forms  the  tubercle, 
but  occasionally  the  tubercle    has  a  distinct   point  of  ossification. 
The  lower  epiphysis  commences  to  ossify  during  the 
second  year,  and  unites  with  the  shaft  at  about  the 
twentieth  year.    The  malleolus  internus  is  occasionally 
formed  from  an  independent  centre. 

Etiology  of  Fractures  of  the  Tibia. — Fractures  of  the 
tibia  alone  are,  in  a  large  majority  of  cases,  produced 
by  direct  blows,  such  as  the  kick  of  a  horse,  or  a  blow 
from  a  stick  of  wood ;  in  one  instance  I  have  seen  it 
broken  by  a  kick  from  a  Dutchman's  boot.  It  is  occa- 
sionally broken  by  a  fall  upon  the  foot,  the  force  of 
the  impulse  being  expended  before  the  fibula  gives 
way,  but  almost  always  the  fibula  breaks  at  the  same 
moment,  or  immediately  after  the  fracture  has  taken 
place  in  the  tibia. 

Dr.  Proudfoot,  of  New  York,  has  reported  an  exam- 
ple of  fracture  of  the  tibia  in  utero,  produced  in  the 
sixth  month  of  pregnancy,  by  violent  pressure  upon 
the  abdomen.' 

Pathology,  Division,  &c. — In  an  analysis  of  twenty- 
seven  fractures  of  the  tibia,  not  including  fractures  of 
the  malleoli,  six  were  found  to  have  occurred  in  the 
upper  third,  eleven  in  the  middle  third,  and  eight  in 
the  lower  third.  .  Six  of  the  twenty-seven  are  known  to 
have  been  transverse,  or  only  slightly  oblique.  It  is 
probable,  also,  that  several  of  the  remainder  were  trans- 
verse. •  In  this  respect,  therefore,  fractures  of  the  tibia 
alone  will  be  found  to  differ  materially  from  fractures  of  the  tibia  and 
fibula;  but  it  is  only  in  accordance  with  the  general  observation  that 
indirect  blows  produce  almost  constantly  oblique  fractures,  and  direct 
blows  somewhat  more  frequently  transverse. 

Many  examples  of  fractures  of  the  tibia  extending  into  the  knee- 
joint  are  recorded  by  surgeons,  most  of  which  were  compound,  or 
otherwise  seriously  complicated,  so  as  to  render  amputation  necessary, 
and  the  consideration  of  which  scarcely  belongs  properly  to  a  treatise 
upon  fractures. 

The  malleolus  internus  is  broken  frequently  at  the  same  time  that 
the  ankle-joint  is  dislocated,  and  this  accident  will  be  considered  in 
that  connection. 

Separation  of  Einjjliyses. — "We  have  already  mentioned  that  Madame 
Lachapelle  has  reported  a  case  of  separation  of  the  upper  epiphysis  of 
the  tibia,  and  of  the  lower  epiphysis  of  the  femur,  occasioned  by 
pulling  at  the  foot  during  birth. 

^  Dr.  Voss,  of  New  York,  has  seen  a  separation  of  the  lower  epiphy- 
sis in  a  boy  14  years  old,  who  in  falling  had  caught  his  foot  between 
two  blocks  of  wood.     The  upper  fragment  protruded  through  the 


Development  of 
the  tibia.  (From 
Gray.) 


'  Proudfoot,  Bost.  Med.  and  Surg.  Journ.,  vol.  xxxv.  p.  268,  184G ;  from  New- 
York  Journ.  Med. 


446  FEACTURES    OF    THE    TIBIA. 

skin.  Reduction  was  effected,  but  subsequently  a  portion  of  the 
epiphysis  became  necrosed  and  was  removed.  He  finally  recovered 
with  a  useful  joint.^ 

Dr  .R.  W.  Smith  has  reported  a  similar  case  in  a  boy  16  years 
of  age,  and  which,  having  occurred  six  months  before,  remained  unre- 
duced. The  lower  end  of  the  shaft  was  displaced  forwards.  Richard 
Qaain  records  one  other  example,  in  a  lad  17  years  old,  which  was 
easily  reduced  and  maintained  in  position.^ 

Prognosis. — No  shortening  can  occur  in  this  fracture  unless  one  or 
both  ends  of  the  fibula  are  displaced,  a  complication  which  I  have 
noticed  in  two  instances,  but  in  neither  case  did  the  shortening  exceed 
one-quarter  of  an  inch ;  unless,  indeed,  the  fracture  occurs  above  the 
fibula,  or  the  fibula  bends  and  remains  bent,  or  the  comminution  and 
direction  of  the  fracture  is  such  at  either  end  as  to  allow  the  femur 
or  the  astragalus  to  become  impacted.  I  have  never  recognized  either 
of  these  conditions. 

Occasionally  the  upper  fragment  has  been  slightly  displaced  for- 
wards. With  these  exceptions,  and  one  other  of  delayed  union  which 
I  shall  presently  mention,  this  bone,  in  my  experience,  has  been  found 
to  unite  promptly  and  without  any  appreciable  deformity.  Other 
surgeons  have  noticed  occasionally  that  the  upper  end  of  the  lower 
fragment  has  become  displaced  toward  the  fibula.  Dr.  Donne,  of 
Louisville,  has  reported  an  example  of  delayed  union  in  a  simple 
transverse  fracture  of  the  upper  end  of  the  tibia.  The  man  was  in- 
temperate. Ten  weeks  after  the  accident  no  union  had  occurred,  and 
Dr.  Donne  introduced  a  seton,  and  in  about  six  weeks  the  fragments 
were  firm.^ 

If  the  fracture  extends  into  either  the  knee  or  ankle-joint,  the  danger 
of  anchylosis  is  imminent,  yet  experience  has  shown  that  it  may  some- 
times be  avoided. 

When  the  malleolus  is  broken  off,  it  generally  becomes  slightly 
displaced  downwards,  and  in  this  position  a  complete  bony  or  liga- 
mentous union  takes  place. 

Treatment. — The  tendency  to  displacement,  in  a  fracture  of  the  tibia, 
is  usually  so  slight,  if  it  exists  at  all,  that  simple  dressings,  light 
splints  of  leather,  felt,  or  binder's  board,  with  rest  in  the  horizontal 
posture  upon  a  pillow,  fulfil  nearly  all  the  indications  which  are 
present.  The  following  cases  will  illustrate  the  usual  course  of  these 
accidents. 

Mrs.  W.  fell,  Oct.  19,  1848,  striking  on  her  right  knee,  breaking 
the  tibia  transversely  just  below  the  tuberosity. 

The  fall  was  the  result  of  a  misstep  on  level  ground,  and  was  at- 
tended with  only  slight  bruising  of  the  soft  parts.  She  says  that  on 
attempting  to  rise  she  discovered  what  had  happened,  the  bone  pro- 
jecting very  distinctly,  and  she  pushed  and  pulled  it  into  place  with 
her  own  hands. 

•  Voss,  N.  Y.  Journ.  Med.,  Nov.  1865,  p.  133. 

2  New  York  Journ.  Med.,  June,  18G8,  from  British  Med.  Journ.,  Aug.  31,  1867. 
'  Donne,  Amer.  Journ.  Med.  Sci.,  vol.  xxviii.  jj.  534;   from  Western  Journ. 
Med.  and  Surg.,  Aug.  1841. 


FRACTUEES    OF    THE    TIBIA.  447 

I  dressed  the  limb  by  laying  it  upon  a  pillow,  outside  of  which 
were  placed  two  broad  deal  splints,  tying  the  whole  snugly  together 
with  several  strips  of  bandage.  At  a  later  period  the  leg  and  thigh 
were  laid  over  a  double-inclined  plane. 

At  the  end  of  six  weeks  all  dressings  were  removed,  and  the  frag- 
ments were  found  to  have  united  firmly,  and  so  perfectly  as  that  the 
point  of  fracture  could  not  be  traced. 

Peter  Hamil,  set.  29,  was  admitted  into  the  hospital  Aug.  31,  1849, 
with  an  injury  to  his  left  leg,  which  had  occurred  two  days  before. 
A  young  surgeon  had  examined  the  limb,  and  thought  the  femur  was 
broken  just  above  the  joint.  He  bad  applied  a  roller  from  the  toes 
to  the  thigh;  and  to  the  thigh  were  applied  lateral  splints.  These 
dressings  were  on  the  limb  at  the  time  of  his  admission,  and  were 
not  removed  until  the  next  day.  I  could  not  then  discover  any 
fracture  or  displacement,  and  the  dressings  were  discontinued,  the 
limb  being  merely  laid  upon  pillows. 

Oct.  4,  when  examining  the  limb,  I  detected  a  slipping  sensation, 
like  that  produced  in  a  false  joint,  through  the  upper  end  of  the  tibia, 
and  I  now  easily  understood  what  had  been  mistaken  for  a  fracture  of 
the  femur.  It  was  a  transverse  fracture  through  the  upper  end  of  the 
tibia,  and  without  displacement. 

No  splints  were  afterwards  applied,  and  on  the  25th  of  November, 
three  months  after  admission,  he  was  dismissed,  the  motion  between 
the  fragments  having  ceased,  but  the  knee  still  remaining  quite  stiff. 

The  presence  of  inflammation,  with  other  complications,  may,  how- 
ever, occasionally  render  the  treatment  m.ore  difficult  and  the  results 
less  satisfactory. 

John  Mahan,  get.  39,  admitted  to  the  hospital  Feb.  16,  1853,  with 
a  compound  fracture  of  the  right  tibia,  near  the  middle  of  the  leg. 
The  bone  was  broken  by  the  kick  of  a  Dutchman.  I  found  the  limb 
much  swollen  and  very  painful,  and  I  laid  it  carefully  over  a  double- 
inclined  plane,  and  directed  cold  water  irrigations;  I  also  directed 
morphine  in  full  doses.  The  inflammation  for  several  days  threatened 
the  complete  loss  of  his  limb.  On  the  tenth  day  the  distal  end  of  the 
upper  fragment  was  projecting  in  front  of  the  lower,  and  I  depressed 
the  angle  of  the  splint  and  made  moderate  pressure  upon  the  upper 
fragment.  On  the  twentieth  day  the  fragments  were  bent  backwards, 
and  I  placed  a  compress  behind.  On  the  thirty-seventh  day  we  took 
the  limb  from  the  inclined  plane,  and  trusted  alone  to  side  splints. 
On  the  forty-fifth  day  we  removed  all  dressings.  The  fragments  had 
not  united.  The  limb  was  then  laid  upon  a  pillow,  and  six  days  later 
a  firm  gutta-percha  splint  was  applied  for  the  purpose  of  steadying 
the  bone,  but  the  splint  was  removed  daily  in  order  that  the  leg 
might  be  bathed  and  rubbed.  He  was  allowed  to  sit  up.  On  the 
fifty-ninth  day  motion  could  still  be  perceived  between  the  fragments, 
and  he  was  directed  to  use  crutches.  On  the  ninety-third  day  the 
union  was  found  to  be  firm,  the  upper  fragment  remaining  slightly 
displaced  forwards. 

In  case  the  fracture  extends  into  the  knee-joint,  it  is  best  to  lay  the 


448  FRACTURES    OF    THE    TIBIA. 

limb  upon  pillows  or  in  a  nicely-cushioned  box,  and  nearly  straight. 
No  extension  or  counter-extension  is  necessary  here  any  more  than 
in  other  fractures  of  the  tibia  alone,  nor  are  lateral  splints  or  rollers 
necessary  or  proper  at  first,  as  a  general  rule ;  but  especial  attention 
should  constantly  be  given  to  the  prevention  of  inflammation,  and  of 
subsequent  anchylosis.  The  omission  to  employ  splints  in  a  case  of 
this  kind  was  charged  against  a  surgeon  in  Vermont  as  evidence  of 
malpractice.  I  am  happy  to  say,  however,  that,  in  this  particular  case, 
he  was  sustained  by  the  testimony  of  the  medical  men  and  by  the 
verdict  of  the  jury;  but  the  attempt  which  the  reporter  has  made  to 
defend  this  as  a  universal  practice  in  fractures  of  the  leg,  or  of  the 
tibia  alone,  is  unfortunate,  and  evinces  a  lack  of  practical  experience.* 

Whatever  position  is  adopted,  and  whatever  means  of  support  or 
retention  are  employed,  if  bandages  and  splints  are  applied  tightly  or 
injudiciously,  great  suffering  and  irreparable  mischief  to  the  knee-joint 
may  be  the  consequence. 

A  man,  set.  23,  entered  the  Pennsylvania  Hospital,  July  18,  1839, 
with  an  oblique  fracture  through  the  head  of  the  tibia.  A  phj^sician 
had  applied  a  bandage  and  splint  to  the  leg,  and  sent  him  twenty  miles 
to  the  city,  and,  on  examination  after  his  arrival,  the  whole  limb  as 
high  as  the  groin  was  much  swollen,  red,  and  excessively  painful. 
The  knee-joint  was  distended  and  very  tender.  All  dressings  were 
immediately  removed,  and  the  limb  laid  in  a  long  fracture-box  slightly 
elevated  at  the  foot;  cool  lotions  were  applied,  and  the  patient  was 
freely  bled,  both  from  the  arm  and  by  the  application  of  leeches.  The 
limb  was  kept  in  this  position  about  six  weeks,  and  at  the  end  of  two 
or  three  weeks  more  he  was  dismissed,  cured.  Dr.  Norris,  who  was 
the  hospital  surgeon  in  attendance,  has,  in  his  report  of  the  case,  very 
properly  taken  this  occasion  to  warn  surgeons  of  the  danger  of  exces- 
sive bandaging  and  splinting  in  this  kind  of  fracture,  as  well  as  in  all 
other  fractures  of  the  lower  extremities.^ 

Fractures  of  the  malleolus,  unaccompanied  with  any  other  accident, 
demand  only  that  the  limb  should  be  laid  upon  its  outer  or  fibular 
side,  with  the  foot  so  supported  as  that  it  shall  incline  inwards  towards 
the  tibia.  In  this  simple  disposition  of  the  limb  we  have  done  all  that 
can  be  done  by  any  mechanical  contrivance  toward  approaching  the 
lower  fragment  to  the  shaft  from  which  it  has  been  broken. 

'  Boston  Med.  Jonrn.,  vol.  liv.  p.  1,  March,  1856. 

2  Norris,  Amer.  Jouru.  of  Med.  Sci.,  vol.  xxiii.  p.  391. 


FRACTURES    OF    THE    FIBULA. 


Ud 


CHAPTER    XXXI. 


FRACTURES  OF  THE  FIBULA. 


Ficr. 


Development  of  the  Fibula. — The  fibula  is  formed  from  three  centres 
of  ossification — one  for  the  shaft,  and  one  for  each  extremity.  Bone 
begins  to  be  deposited  in  the  shaft  at  about  the  sixth 
week  of  foetal  life,  in  the  lower  extremity  during  the 
second  year,  and  the  upper  extremity  during  the  fourth 
year.  The  lower  epiphysis  unites  with  the  shaft  about 
the  twentieth  year,. and  the  upper  about  the  twenty-fifth 
year. 

I  have  not  found  any  recorded  examples  of  separation 
of  these  epiphyses. 

Causes  of  Fracture. — In  a  record  of  thirty-two  cases  I 
have  been  able  to  ascertain  the  cause  satisfactorily  in 
eighteen,  of  which  number  three  were  the  results  of  falls 
directly  upon  the  bottom  of  the  foot,  but  which  were 
probably  accompanied  with  a  twist  of  the  foot,  four  of  a 
slip  of  the  foot  in  walking  on  level  ground,  or  on  ground 
only  slightly  irregular,  and  twelve  of  direct  blows. 

Pathology. — In  all  of  the  fractures  which  have  been 
produced  by  falls  upon  the  bottom  of  the  foot,  and  in  all 
except  one  produced  by  a  slip  of  the  foot,  the  accident 
was  accompanied  with  a  dislocation  of  the  ankle;  the 
foot  being  turned  outwards.  In  the  one  exceptional 
case  mentioned,  the  dislocation  may  also  have  occurred, 
but  the  fact  is  not  known. 

Both  Malgaigne  and  Dupuytren  have  noticed  a  dis- 
location iti  the  opposite  direction,  or  a  turning  of  the 
foot  inwards,  more  often  than  a  turning  outwards.  I 
cannot  think  their  observations  were  carefully  made. 

Moreover,  in  at  least  seven  of  the  twelve  fractures  pro- 
duced by  direct  blows  the  tibia  has  been  thrown  more  or  less  inwards, 
and  consequently  the  foot  has  turned  out. 

In  twenty-four  examples  the  fracture  of  the  fibula  has  taken  place 
within  from  two  to  five  inches  of  the  lower  end  of  the  bone.  Twice 
the  external  malleolus  was  broken  off,  and  seven  times  the  internal 
malleolus. 

Four  of  the  fractures  occurring  in  consequence  of  direct  blows  were 
compound,  and  one  was  also  comminuted. 

Prognosis. — In  a  majority  of  cases,  where  the  fibula  has  been  broken 
from  two  to  five  inches  above  the  lower  end,  the  fragments  have  united 
inclined  toward  or  resting  against  the  tibia;  occasionally  I  have  seen 


Develupmeat  of 
the  Fibula.  (From 
Gray.) 


450 


FEACTURES    OF    THE    FIBULA. 


Fig.  201. 


them  displaced  backwards  or  forwards.     Once  the  fibula  refused  to 
unite  altogether. 

The  malleoli  have  generally  united  nearly  or  quite  in  place,  but  in 
two  instances  the  external  malleolus  has  been  found  displaced  very 
much  downwards. 

Of  the  compound  fractures,  two  required  amputation,  one  was  treated 
by  resection  of  the  lower  end  of  the  tibia,  and  one 
died  without  any  operation.  Douglas  has  reported 
a  case  of  compound  dislocation  with  fracture  of  the 
fibula,  which  being  reduced,  he  was  able  to  save  the 
limb,  but  not  without  much  difficulty,  and  the  ankle 
remained  stiflf.^  Other  surgeons  have  met  with  simi- 
lar success,  but  I  shall  refer  to  this  subject  again 
under  the  head  of  compound  dislocations. 

Of  those  which  recovered,  twenty-eight  in  number, 
ten  have  been  found  to  have  more  or  less  unnatural 
prominence  of  the  internal  malleolus,  and  in  two  of 
these  the  malleolus,  or  lower  end  of  the  tibia,  projects 
very  much.  In  nearly  all  of  these  examples  the  foot 
appears  somewhat  inclined  outwards. 

Generally  the  ankle-joint  has  remained  stiff  for 
some  time  after  the  bandages  have  been  removed; 
and  probably  in  all  cases  in  which  the  accident  was 
accompanied  with  a  dislocation  of  the  tibia.  But 
this  stiffness  has  usually  disappeared  after  a  few 
weeks  or  months.  Twice  I  have  noticed  considerable 
stiffness  after  about  six  months;  three  times  after  one  year;  in  one 
case  after  two  years ;  and  in  one  case  after  twenty  years  the  ankle 
would  occasionally  swell,  and  become  quite  stiff".  In  one  case  it  re- 
mained almost  immovable  after  twenty  years ;  and  in  a  still  more 
remarkable  instance,  I  examined  the  limb  thirty  years  after  the  acci- 
dent, when  the  man  was  sixty-three  years  old,  and  although  there 
existed  no  swelling  or  deformity,  yet  this  leg  was  not  as  muscular 
as  the  other,  and  he  declared  that  up  to  this  time  the  ankle  remained 
quite  tender  to  the  touch,  and  that  occasionally  it  became  painful. 

When  I  come  to  speak  of  dislocation  of  the  ankle,  I  shall  adopt 
the  usual  nomenclature,  and  shall  name  all  those  dislocations  in  which 
the  tibia  projects  inwards  from  the  foot,  "inward  dislocations  of  the 
tibia;"  yet  I  have  some  doubts  as  to  the  propriety  of  this  appellation. 
This  accident  seems  to  me  to  have  been  in  general  rather  a  lateral 
rotation  of  the  foot,  or  of  the  astragalus,  upon  the  lower  articulating 
surfaces  of  the  tibia  and  fibula.  Of  all  the  ginglymoid  joints,  the 
ankle  approaches  most  nearly  in  form  to  a  ball  and  socket  joint,  in 
consequence  especially  of  the  marked  prolongations  of  the  malleolus 
internus  and  externus.  In  other  ginglymoid  articulations  lateral  dis- 
placements are  not  unfrequent,  but  lateral  rotation  can  scarcely  by 
any  accident  occur.     Here,  however,  the  reverse  holds  true ;  lateral 


Tractuie    of    fibula 
near  lower  end. 


'  Boston  Med.  and  Surg.  Journ.,  vol.  xxxiy.  p.  336,  from  Southern  Journ.  of  Med. 


FRACTURES    OF    THE    FIBULA.  451 

displacement  is  difficult,  wliile  lateral  rotation  is  comparatively  easy 
of  accomplishment. 

The  majority  of  cases  which  occur,  involving  a  disturbance  of  the 
relative  position  of  the  ankle-joint  surfaces,  are,  I  am  satisfied,  of  this 
latter  character,  viz.,  lateral  rotations  within  the  capsule,  rather  than 
true  dislocations;  and  although  the  restoration  of  the  joint  surfaces 
to  position  is,  in  general,  easily  accomplished,  yet,  in  consequence  of 
either  a  fracture  of  the  fibula  or  malleolus  internus,  or  of  a  rupture 
of  the  internal  lateral  ligaments,  it  will  generally  happen  that  some 
deformity  will  remain.  The  fragments  of  the  fibula  will  fall  inwards 
towards  Ihe  tibia,  and  the  foot,  unsupported  by  either  its  fibula  or  its 
internal  ligaments,  will  incline  perceptibly  outwards.  Nor  can  this  be 
wholly  prevented,  in  most  cases,  by  any  mechanical  contrivance.  In- 
deed, it  would  be  easy  to  demonstrate,  as  I  have  often  done  to  my 
pupils,  that  even  Dupuytren's  splint,  usually  employed  in  this  acci- 
dent, must  fail  of  success  in  a  great  majority  of  cases,  since  the  sub- 
sequent deformity  is  due  less  to  the  fracture  of  the  fibula  and  its 
consequent  displacement  than  to  the  loss  of  the  internal  ligaments, 
which  loss  nature  can  seldom  fully  repair.  As  further  evidence  of 
the  correctness  of  this  view,  I  will  state  that  in  three  of  the  examples 
in  which  I  have  found  the  fractured  fibula  united  and  resting  against 
the  tibia,  the  motions  of  the  ankle-joint  have  been  completely  re- 
covered. 

If,  however,  it  were  true  that  a  fracture  and  displacement  of  the 
fibula  is  the  sole  or  essential  cause  of  the  subsequent  deformity,  it 
would  still  be  found  often  impracticable  to  avoid  the  maiming,  since 
it  would  still  remain  impossible  to  lift  the  broken  ends  from  the  tibia, 
against  which,  or  in  the  direction  toward  which,  they  are  so  prone  to 
fall.  Inversion  of  the  foot  does  not  accomplish  it,  nor  have  I  ever 
been  able  to  make  anything  but  the  most  trivial  impression  upon  the 
upper  end  of  the  lower  fragment  by  pressure  upon  the  lower  extremity 
of  the  fibula. 

I  think  too  much  confidence  has  been  placed  in  the  efficiency  of 
"Dupuytren's  splint."  I  believe,  indeed,  that  this  splint  is  a  very 
appropriate  means  of  support  and  retention  after  this  accident;  but 
I  doubt  whether  it  is  able  to  accomplish  all  that  its  illustrious  inventor 
proposed. 

Ih-eatment. — Dupuytren's  mode  of  dressing  is  essentially  as  fol- 
lows:— 

A  pad,  or  long  junk,  made  of  a  piece  of  cotton  cloth,  stuffed  with 
cotton  batting,  is  constructed  of  sufficient  length  to  extend  from  the 
condyles  of  the  femur  to  a  point  just  above  the  malleolus  internus. 
This  pad  must  be  about  five  or  six  inches  in  width,  and  thicker  by 
two  or  three  inches  at  its  lower  than  its  upper  end.  This  is  to  be  laid 
upon  the  inside  of  the  leg,  with  its  base  or  thickest  portion  resting 
against  the  tibia  just  above  the  internal  malleolus.  Over  this  pad  is 
to  be  placed  a  long  firm  splint,  extending  also  from  above  the  knee 
to  three  inches  beyond  the  bottom  of  the  foot.  With  a  few  turns  of 
a  roller  the  upper  end  of  the  splint  will  now  be  made  fast  to  the 


452 


IPRACTUEES    OF    THE    FIBULA. 


Fi£r, 


knee,  and  with  a  second  roller  the  lower  end  must  be  secured  to  the 
foot.  The  application  of  this  last  bandage  requires,  however,  some 
care  in  its  adjustment.  Its  purpose  is  simply  to  rotate 
the  foot  inwards,  while  at  the  same  time  the  tibia  is  pressed 
outwards;  and  to  this  end  it  must  be  applied  in  the  form 
of  a  figure-of-8  over  both  splint  and  foot,  embracing  al- 
ternately the  heel  and  the  instep.  In  order  to  be  effectual, 
it  must  be  drawn  pretty  firmly,  and  no  portion  of  the 
bandage  must  pass  higher  than  the  malleolus  externus. 
In  some  surgical  books  I  have  seen  this  apparatus  repre- 
sented with  a  roller  embracing  the  whole  length  of  the 
leg ;  and  in  others  it  is  represented  as  encircling  the  limb 
two  or  three  inches  above  the  malleolus;  but  it  is  evident 
that  these  modes  of  dressing  must  defeat  the  great  object 
which  Dupuytren  had  in  view,  namely,  the  throwing  out 
of  the  upper  end  of  the  lower  fragment. 

When  the  limb  is  thus  dressed,  the  knee  may  be  flexed 
and  the  leg  laid  upon  its  outside,  supported  by  a  pillow, 
or  upon  its  inside,  as  in  the  accompanying  engraving. 

If  it  is  only  a  fracture  of  the  external  malleolus,  or  if 
the  fracture  has  occurred  in  the  middle  or  upper  third  of 
the  bone,  this  treatment  is  no  longer  appropriate,  and  it 
will  generally  be  found  sufficient  to  place  the  limb  at  rest  for  a  few 
days  upon  a  suitable  cushion  or  upon  a  pillow. 

Of  late  years  I  have  not  employed  Dupuytren's  splint  quite  so 
much  as  formerly,  and  especially  because  I  have  met  with  several 
examples  of  backward  displacement  of  the  foot  following  fractures  of 
the  fibula,  which  Dupuytren's  splint  is  not  competent  to  prevent  or  to 


Dupuytren's 
splint  incor- 
rectly applied. 


Fisr.  203. 


Dupuytren's  splint  as  originally  applied  by  himself. 


remedy.  This  subject  will  be  considered  more  fully  in  connection 
with  forward  luxations  of  the  tibia  at  its  lower  end ;  but  it  is  neces- 
sary to  say  here  that  this  accident  can  be  most  certainly  avoided  by 
employing  the  plaster-of- Paris  or  starch  dressing;  taking  care  in 
applying  the  dressing  to  secure  a  thorough  inversion  of  the  toes  and 
foot,  the  same  as  in  case  the  limb  were  dressed  with  Dupuytren's 
splint.  Care  must  be  taken,  also,  not  to  press  upon  the  limb  much 
with  the  bandages  above  the  malleolus  externus.  The  same  results 
may  be  attained,  also,  by  a  well-adjusted  leather  splint,  or  by  two 
splints,  which  shall  inclose  the  heel  as  well  as  the  sides  and  front  of 
the  limb. 

It  is  scarcely  necessary  to  say  that,  since  after  this  accident  anchy- 
losis is  so  frequent,  early  and  unremitting  attention  should  be  given 


FRACTURES    OF    THE    TIBIA    AND    FIBULA.  453 

to  the  establishment  of  passive  motion  in  the  joint.  Indeed,  I  cannot 
but  think  that  a  desire  to  accomplish  the  indications  recognized  and 
uro^ed  by  Dupuytren  has  led  to  the  neglect  of  the  indication  which 
ought  to  have  been  regarded  as  of  equal,  if  not  of  the  greatest,  im- 
portance, namely,  the  prevention  of  contractions  and  adhesions  around 
and  between  the  joint  surfaces. 

As  a  general  rule,  the  dressings  ought  to  be  wholly  laid  aside  by 
the  end  of  the  third  or  fourth  week ;  and  although  it  may  be  well  for 
a  somewhat  longer  time  to  keep  the  foot  turned  in,  by  having  it  pro- 
perly supported  as  it  lies  upon  the  pillow,  yet  after  this  date  I  regard 
the  use  of  splints  and  bandages  as  only  pernicious. 


CHAPTER    XXXII. 

TRACTUKES  OF  THE  TIBIA  AND  FIBULA. 

Causes.— Yrohahly  four-fifths  of  these  fractures  are  the  results  of 
direct  blows  or  of  crushing  accidents,  such  as  the  kick  of  a  horse,  the 
passage  of  a  loaded  vehicle  across  the  limb,  the  fall  of  heavy  stones  or 
timbers,  &c. 

In  an  analysis  of  one  hundred  and  eleven  cases,  i  find  the  bones 
broken  in  the  upper  third  from  a  direct  cause  four  times,  and  from  an 
indirect  cause  once.  In  the  middle  third  forty  have  been  referred  to 
a  direct  cause,  and  two  to  an  indirect;  and  in  the  lower  third  thirty- 
nine  to  a  direct  cause,  and  eighteen  to  an  indirect.  An  observation 
which  does  not  sustain  the  remark  of  Malgaigne,  based  upon  his 
analysis  of  sixty-seven  cases,  that  fractures  of  the  upper  third  are 
produced  by  direct  causes  alone,  those  of  the  middle  third  much  more 
frequently  by  indirect  causes,  and  that  those  of  the  lower  third  are 
especially  due  to  indirect  causes.  Direct  causes  produce  a  large 
majority  of  the  fractures  of  the  lower  third,  but  the  proportion  is 
smaller  than  in  the  middle  third. 

Of  the  indirect  causes,  falls  upon  the  feet  from  a  considerable  height 
— as  from  a  scaffolding,  or  from  the  top  of  a  building — are  by  far  the 
most  common.  Four  times  I  have  found  the  bones  broken  by  muscu- 
lar action  alone,  as  in  the  following  example: — 

Mrs.  W.,  of  Buffalo,  aged  about  twenty-five  years,  and  weighing  at 
this  time  nearly  two  hundred  pounds,  was  descending  her  door-steps 
with  an  infant  in  her  arms,  when,  the  step  being  covered  with  ice,  she 
slipped  and  fell,  breaking  her  right  leg  just  above  the  ankle.  Mrs.  W. 
says  she  felt  and  heard  the  bones  snap  before  she  touched  the  steps. 
Of  this  she  is  certain. 

We  found  the  tibia  broken  obliquely,  the  fragments  being  quite 
movable,  but  not  much,  if  at  all,  displaced.  The  limb  was  dressed 
with  a  carefully  moulded  and  well-padded  gutta-percha  splint,  and 
then  laid  in  a  pillow  upon  the  bed.     Mrs.  W.  experienced  unusual 


454  FRACTUEES    OF    THE    TIBIA    AND    FIBULA. 

pain  from  the  fracture  for  several  days,  for  the  relief  of  which  we  were 
compelled  at  times  to  permit  her  to  inhale  chloroform.  She  was  of  a 
nervous  temperament,  and  had  frequently  resorted  to  chloroform 
before  to  relieve  neuralgic  pains.  The  limb  became  very  much 
swollen,  and  remained  so  for  a  week  or  two.  No  extension  was  ever 
employed. 

Within  the  usual  time  the  bones  united  in  perfect  apposition,  and 
in  about  four  months  she  was  able  to  walk  without  any  halt. 

Pathology,  Symptoms,  &c. — We  have  seen  that  fractures  of  both 
bones  through  some  part  of  the  lower  third  are  most  frequent.  Thus, 
of  one  hundred  and  fifty-five  fractures,  eleven  belonged  to  the  upper 
third,  forty-five  to  the  middle,  and  ninety-three  to  the  lower.  In  six 
cases  the  two  bones  were  broken  in  different  divisions.  It  is  probable 
that  in  this  analysis  some  errors  have  occurred,  and  that  in  a  larger 
proportion  than  here  stated  the  two  bones  have  given  way  at  opposite 
extremities,  since  it  is  often  difficult,  and  sometimes  quite  impossible, 
to  determine  precisely  where  the  fibula  is  broken;  but  the  analysis  is 
sufficiently  correct  to  illustrate  the  much  greater  frequency  of  fractures 
of  the  lower  third,  and  also  the  fact  that  the  two  bones  generally 
break  nearly  on  the  same  level;  usually  the  point  of  fracture  in  the 
tibia  is  between  two  and  three  inches  above  the  joint. 

In  an  examination  of  twenty  museum  specimens,  I  have  found  both 
bones  broken  at  the  same  point,  or  within  two  or  three  inches  of  the 
same  point,  sixteen  times,  and  at  extreme  points  four  times ;  and  in 
these  last  examples  the  tibia  has  always  been  broken  in  the  lower 
third,  while  the  fibula  has  been  broken  in  the  upper  third. 

In  seventeen  of  the  fractures  mentioned  as  belonging  to  the  lower 
third  only  the  malleolus  of  the  tibia  was  broken,  while  the  fibula  was 
broken  two  or  three  inches  above  its  lower  end.  Some  of  these  were, 
perhaps,  examples  of  dislocation  of  the  ankle. 

I  have  seldom  seen  a  transverse  fracture  of  the  tibia,  except  in  its 
lower  or  upper  extremity,  in  the  expanded  portions  of  the  bone ;  and 
even  in  those  examples  which  we  are  accustomed  to  call  transverse, 
because  they  are  sufficiently  so  to  prevent  any  sliding  or  overlapping 
of  the  fragments,  there  has  existed,  generally,  a  marked  inclination  of 
the  line  of  fracture  in  one  direction  or  another. 

The  examples  of  fracture  produced  by  muscular  action  have,  with- 
out an  exception,  occurred  in  adults.  Three  of  them  were  in  the  lower 
third  of  the  leg,  and  one  in  the  middle  third.  I  think  they  were,  all 
of  them  nearly  transverse,  since  they  never  became  much,  if  at  all, 
displaced. 

Most  of  the  fractures  of  the  tibia  produced  by  falls  upon  the  feet 
are  very  oblique,  and  the  direction  of  the  fracture  is  generally  down- 
wards, forwards,  and  inwards;  but  I  have  found  almost  every  con- 
ceivable variation  from  this  general  rule. 

The  fracture  in  the  fibula  is  even  more  constantly  oblique  than  the 
fracture  in  the  tibia;  but  this  is  a  point  of  very  little  practical  conse- 
quence, and  one  which  we  can  seldom  determine  positively,  unless  one 
of  the  fractured  ends  protrudes  through  the  flesh. 

Compound  and  comminuted  fractures  are  more  frequent  here  than 


FRACTURES    OF    THE    TIBIA    AND    FIBULA.  455 

in  any  other  of  the  bones  of  the  body.  My  tables,  which  have  rejected 
all  fractures  demanding  immediate  amputation,  most  of  which  are 
compound,  do  not  for  this  reason  give  a  just  idea  of  their  proportion 
to  simple  fractures;  yet  even  in  these  tables,  of  one  hundred  and 
seventy-two  fractures,  sixty-two  were  compound,  and  also,  generally, 
more  or  less  comminuted.  Of  eighty  cases  reported  by  W.  W.  Mor- 
land,  of  Boston,  from  the  Massachusetts  General  Hospital,  and  in 
which  the  character  of  the  accident  is  recorded,  thirty-nine  were  com- 
pound.^ 

The  symptoms  indicating  a  fracture  of  both  bones  of  the  leg  are  the 
same  which  are  usually  present  in  other  fractures,  namely,  mobility, 
crepitus,  shortening  of  the  limb,  distortion,  swelling,  &c.     Generally 

Fis:.  204. 


Compound  and  comminuted  fracture  of  the  leg. 

the  lower  end  of  the  upper  fragment  projects  in  front,  and  can  be  seen 
or  felt;  but  in  some  instances  the  swelling  follows  so  rapidly  that  it  is 
impossible  to  feel  distinctly  the  point  of  fracture,  and  its  existence  can 
only  be  determined  by  the  crepitus,  mobility,  and  shortening  of  the 
limb,  or,  perhaps,  by  the  marked  deformity  or  deviation  from  the 
natural  axis. 

The  shortening,  where  it  exists  at  all,  varies  at  the  first  from  a  line 
or  two  to  a  half  or  three-quarters  of  an  inch.  Generally,  it  is  about 
half  an  inch. 

Prognosis. — The  average  period  of  perfect  union  in  twenty-nine 
cases,  including  those  in  which  union  was  delayed  by  extraordinary 
causes  beyond  the  usual  time,  was  forty  days.  The  general  average 
under  ordinary  circumstances  may  be  stated  at  about  thirty  days. 

Union  has  been  delayed  in  seven  cases,  five  of  which  were  simple 
fractures,  and  two  were  compound.  The  longest  period  w^as  seventeen 
weeks. 

F.  C.  T.,  of  Erie  Co.,  N.  Y.,  oet.  35,  had  an  oblique,  simple  fracture 
of  both  bones,  in  the  upper  third,  caused  by  jumping  from  a  buggy,  in 
June,  1852. 

The  limb  was  dressed  with  lateral  splints,  compresses,  and  bandages, 
and  laid  upon  a  pillow. 

'  Transac.  of  Mass.  Med.  Soc.  for  1840 ;  Fractures,  by  A.  L.  Pierson. 


456  FEACTUEES    OF    THE    TIBIA    AND    FIBULA. 

Eight  weeks  after  the  fracture  had  occurred,  the  gentlemen  in 
attendance  wished  me  to  see  the  limb  with  them.  I  found  Mr.  T.  still 
in  bed,  and  the  fragments  not  at  all  united. 

Mr.  T.  had  enjoyed  average  health  heretofore,  but  he  was  never 
very  robust.  When  I  was  called  to  see  him  he  looked  pale;  his  skin 
was  cold  and  moist,  pulse  120,  and  appetite  poor.  The  broken  leg 
and  foot  were  greatly  swollen.  The  swelling  was  oedematous.  Con- 
siderable excoriations  existed  on  the  back  of  the  leg.  The  fragments 
were  quite  movable,  and  were  overlapped  three-quarters  of  an  inch. 

We  agreed  that  the  patient  ought,  as  soon  as  possible,  to  be  got  out 
of  bed,  so  as  to  enable  him  to  recover  his  strength,  which  had  sadlv 
declined.  To  this  end,  a  gutta-percha  splint  was  made  to  fit  accurately 
the  whole  length  of  the  leg ;  and,  having  attached  a  large  number  of 
tapes,  it  was  to  be  secured  upon  the  limb.  Several  times  each  day  it 
was  to  be  removed,  and  the  limb  bathed  with  brandy  and  water. 
Gradually,  also,  the  limb  was  to  be  brought  down  to  the  floor,  and  the 
patient  be  made  to  sit  up,  and,  as  soon  as  possible,  he  was  to  walk 
with  crutches,  or  to  ride. 

Nov.  4,  1852,  Mr.  T.  visited  me  at  my  house.  The  directions  had 
been  followed  implicitly.  About  two  weeks  after  my  visit  he  rode 
out,  and  in  about  nine  weeks,  or  seventeen  weeks  from  the  time  of 
the  fracture,  the  bones  were  found  united.  His  health  and  strength 
were  quite  restored,  and  the  limb  was  no  longer  oedematous.  It  was 
found  to  be  straight,  or  with  only  a  slight  projection  of  the  upper 
fragment  in  front  of  the  lower,  and  shortened  three-quarters  of  an 
inch. 

A  gentleman,  i^t.  33,  from  Bergen,  N.  Y.,  was  struck  by  a  billet  of 
wood  on  the  3d  of  August,  1856,  breaking  his  left  leg  nearly  trans- 
versely, three  and  a  half  inches  above  the  joint.  The  fracture  was 
simple.  A  surgeon  was  called  immediately,  who  applied  bandages  and 
side  splints,  and  then  laid  the  limb  over  a  double-inclined  plane.  At 
the  end  of  six  weeks  the  dressings  were  removed,  but  the  bones  had 
not  united.  Four  years  after  the  accident,  this  gentleman  consulted 
me.  I  found  him  in  good  health,  but  no  union  had  yet  taken  place. 
This  is  the  only  example,  except  where  amputation  or  death  inter- 
posed, in  which  the  union  has  been  so  long  delayed  as  to  entitle  it  to 
be  considered  as  a  case  of  non-union.  My  own  observation  would, 
therefore,  incline  me  to  think  that,  while  non-union  is  a  rare  event  in 
fractures  of  the  leg,  delayed  union  is  more  frequent  than  in  most 
other  fractures. 

It  has  once  occurred  to  me  to  see  a  complete  non-union  of  the  fibula 
after  a  period  of  several  years,  while  the  tibia  had  united  well.  This 
circumstance  occasioned  no  inconvenience  to  the  patient,  and  was  not 
known  to  him  until  I  had  made  the  discovery. 

A  little  more  than  one-half  of  those  cases  in  which  an  accurate 
note  of  the  result  has  been  made,  have  been  found  to  be  more  or  less 
shortened  by  overlapping,  namely,  sixty-one  cases  out  of  one  hundred 
and  ten.  The  greatest  amount  of  shortening  in  any  one  case  has  been 
one  inch  and  a  half;  and  the  average  shortening  of  the  sixty-one  cases 
has  been  half  an  inch  and  a  fraction  over.    This  analysis  includes  both 


FRACTUEES    OF    THE    TIBIA    AND    FIBULA.  457 

simple  and  compound  fractures;  but  a  pretty  large  proportion  of  the 
simple  fractures  have  also  been  found  shortened,  as  in  the  following 
extreme  illustration : — 

John  Granger,  of  England,  ffit.  43,  was  tripped  by  a  stone  while 
walking,  breaking  his  right  leg  through  its  lower  third.  Fracture 
simple  °and  oblique.  It  was  treated  by  a  surgeon>  of  Hungerford, 
England,  who  employed  only  side  splints. 

Two  years  after,  I  found  the  leg  shortened  one  inch,  the  upper 
fragment  riding  upon  the  front  and  inner  side  of  the  lower. 

Generally,  when  a  shortening  has  occurred,  I  have  found  the  upper 
fragment  in  front  of  the  lower,  and  oftener  a  little  upon  the  inner  than 
upon  the  outer  side. 

The  deviation  from  the  natural  axis  of  the  limb  has  been  noticed 
by  me  in  a  good  many  instances.  Seven  times  the  lower  part  of  the 
limb  has  fallen  backwards,  and  five  times  it  has,  in  a  degree  much 
less  marked,  inclined  inwards.  Once  I  have  seen  it  inclined  outwards, 
and  twice  forwards. 

Ulcers  upon  the  back  of  the  heel,  seen  by  me  seven  times,  as  a  result 
of  undue  pressure  upon  this  part,  have,  however,  been  presented  but 
three  times  in  cases  of  simple  fractures. 

It  is  not  very  unusual  to  find,  also,  over  the  exact  point  of  frac- 
ture, and  after  the  lapse  of  several  months,  or  even  years,  an  ulcer,  or 
sinus,  which  is  due  sometimes  to  the  presence  of  a  small  fragment  of 
bone  which  has  remained  in  the  wound  from  the  time  of  the  accident, 
or  to  a  thin  scale  which  has  subsequently  exfoliated.  In  other  cases 
it  is  due  to  the  prominence  of  the  salient  angle  when  the  lower  part 
of  the  limb  inclines  considerably  backwards,  and  in  still  other  cases, 
no  doubt,  to  the  general  dyscrasy  of  the  system,  and  to  the  same 
causes  which  produce  chronic  ulcers  in  the  lower  extremities  where 
only  the  skin  has  been  originally  injured.  I  have  reported  elsewhere 
examples  of  this  complication  existing  after  five  months,  two  and 
three  years,'  and  in  the  remarkable  case  which  I  shall  now  briefly 
relate  an  ulcer  existed  at  the  end  of  twenty-three  years. 

Thurstone  Carpenter,  when  four  years  old,  received  an  injury,  break- 
ing both  bones  of  one  of  his  legs  near  its  middle.  The  fracture  was 
compound.  It  was  dressed  and  treated  by  an  excellent  surgeon,  then 
residing  in  Buffalo,  but  long  since  dead. 

Twenty-three  years  after  the  accident,  Mr.  Carpenter  called  upon 
me  on  account  of  a  paralysis  of  his  lower  extremities,  which  had 
recently  occurred.  He  stated  that  from  the  time  of  the  fracture  until 
within  about  one  year  an  open  ulcer  had  existed  over  the  seat  of 
fracture,  and  that  soon  after  it  had  closed  over  completely  he  began 
to  lose  the  use  of  his  limbs.  During  the  time  it  was  open,  small  scales 
of  bone  have  frequently  been  thrown  off.  The  limb  is  half  an  inch 
shorter  than  the  other,  but  straight. 

A  gentleman  residing  in  Quincy,  Chautauque  Co.,  IST.  Y.,  had  his 
tibia  and  fibula  broken  near  the  ankle-joint  in  the  year  1844,  by  the- 
passage  of  a  carriage-wheel  across  his  limb.     The  skin  was  a  good 

■  Trans.  Amcr.  Med.  Assoc.     Report  on  Deformities  after  Fracture. 
•60 


458  FEACTUEES    OF    THE    TIBIA    AND    FIBULA. 

deal  lacerated.  The  wounds,  however,  healed  kindlj,  and  the  broken 
bones  united  in  the  usual  time  without  any  apparent  deformity;  but 
the  limb  continued  swollen  and  painful,  until  finally  suppuration  took 
place.  After  twelve  years  of  great  suffering,  I  amputated  the  leg  near 
its  middle,  from  which  time  he  made  a  speedy  recovery.  I  found  the 
lower  end  of  the.  tibia  inflamed,  softened,  and  expanded,  and  contain- 
ing in  its  interior  about  three  ounces  of  pus,  but  no  sequestrum. 

Anchylosis  of  the  knee  or  ankle-joint  may  follow  as  a  result  of  the 
accident  or  of  improper  treatment;  and  at  one  or  both  of  these  joints 
I  have  found  more  or  less  anchylosis  at  the  end  of  nine  months,  one 
year,  six  years,  twenty-five,  thirty,  and  forty  years.  Generally,  how- 
ever, it  disappears  in  a  few  weeks,  and  seldom  remains  to  any  con- 
siderable extent  in  the  knee-joint  after  the  dressings  have  been 
removed  two  or  three  weeks;  but  an  Irishman  called  upon  me  in 
1853,  whose  leg  had  been  broken  about  three  inches  bejow  the  knee- 
joint  six  years  before.  It  was  a  simple  fracture.  A  surgeon  in 
Ireland  had  treated  the  case.  I  found  the  limb  shortened  one  inch 
and  a  half,  the  fragments  being  overlapped  and  displaced  backwards 
at  the  point  of  fracture.  The  knee  was  also  partly  anchylosed.  I 
could  not  learn  what  the  treatment  had  been. 

In  other  cases,  where  no  permanent  anchylosis  has  followed,  the 
ankle-joint  has  been  occasionally  painful,  and  subject  to  swellings, 
after  the  lapse  of  many  years. 

After  all  that  has  been  said  as  to  the  occasionally  serious  nature  of 
the  consequences  of  these  accidents,  as  shown  in  the  shortening  of  the 
limbs,  in  their  deviations  from  their  natural  axes,  in  the  stiff'  ankles, 
ulcers,  and  abscesses,  it  must  be  still  admitted  that  in  another  point  of 
view  these  results  are  not  extraordinary,  and  may  hereafter  continue 
to  be  fairly  anticipated  in  a  certain  proportion  of  cases,  even  under 
the  best  management ;  since  it  must  be  understood  that  more  fractures 
of  the  leg  are  attended  with  serious  complications  than  of  any  other 
limb;  and  that  while  many  produce  death  rapidly  from  the  severity 
of  the  shock,  and  very  many  are  condemned  at  once  to  amputation,  a 
large  number  of  those  which  are  saved  have  been  in  that  condition 
which  has  rendered  the  application  of  bandages  or  splints  impossible 
for  many  days.  Indeed,  not  a  few  of  these  crooked  limbs  may  still 
be  presented  as  real  triumphs  of  the  art  of  surgery,  inasmuch  as  by 
consummate  skill  alone  have  they  been  saved. 

Treatment. — It  is  wholly  impossible  in  a  class  of  fractures  which 
present  so  great  a  variety  in  regard  to  form,  seat,  and  complications, 
to  establish  any  universal  system  of  practice;  nevertheless  it  is 
possible  to  declare  certain  general  principles  in  reference  to  a  few 
well-recognized  classes  or  varieties:  and  I  shall  deem  it  especially 
important  to  record  my  disapproval  of  certain  plans  of  treatment 
which  have  from  time  to  time  been  suggested  and  adopted. 

In  the  revision  of  the  present  edition  I  have  sought  constantly  to 
keep  pace  with  the  progress  of  that  department  of  surgery  of  which 
it  treats,  and  especiall}'  with  my  own  experience;  but  nowhere  have  I 
found  my  own  practice  so  fiir  in  advance  of  my  precepts  as  in  the 
treatment  of  fractures  of  the  leg.     In  my  earlier  editions  I  found  it 


FRACTURES    OF    THE    TIBIA    AND    FIBULA.  459 

necessary  to  combat  strongly  the  then  too  prevalent  custom  of  treating 
simple  fractures  of  the  leg.  as  well  as  compound  fractures,  in  boxes; 
and  also  the  almost  equally  prevalent  custom  in  some  directions  of 
attempting  to  treat  all  fractures  of  the  leg  by  extension.  The  treat- 
ment of  these  fractures  by  the  method  recommended  by  Pott,  the 
distinguished  surgeon  of  St.  Bartholomew's  Hospital,  left  no  oppor- 
tunity for  the  practice  of  either  of  these  popular  errors,  and  it  was 
early  adopted  by  me  as  far  preferable  to  any  then  in  general  use.  I 
have  no  reason  to  regret  my  preference  then  so  fully  expressed.  The 
plan  will  still  be  found  applicable  to  a  large  proportion  of  these 
accidents,  and  will  on  the  whole  give  probably  as  many  favorable 
results  and  occasion  as  few  accidents  as  any  other ;  but  farther  ex- 
perience has  shown  that  one  or  two  other  methods,  which  will  pre- 
sently be  described,  are  in  most  cases  equally  valuable  and  in  some 
cases  manifestly  preferable. 

The  method  recommended  by  Pott  is  as  follows : — 
A  splint  is  constructed,  made  of  a  thin  piece  of  board,  long  enough 
to  extend  from  a  little  above  the  knee  to  a  point  two  inches  beyond 
the  sole  of  the  foot,  about  seven  inches  in  width,  and  reaching  for- 
wards at  the  lower  end,  so  as  to  support  the  foot.  This  splint  is  to 
be  covered  heavily  with  cotton  batting,  in  order  that  it  may  fit  all  the 
inequalities  of  the  outer  side  of  the  leg  and  foot,  taking,  however, 
especial  care  that  there  should  be  a  depression  at  a  point  correspond- 
ing to  the  external  malleolus,  so  deep  as  that  even  when  the  limb  is 
bound  down  to  the  splint  the  malleolus  shall  not  touch.  The  splint 
with  its  padding  must  then  be  covered  with  cotton  cloth  neatly  sewed 
on. 

The  remaining  splint  may  be  made  of  leather,  binder's  board,  felt, 
or  gutta-percha;  but  in  either  case  it  need  not  extend  higher  than 

Fig.  205. 


Long  splint  for  treatment  of  a  fracture  of  the  leg  in  Pott's  position. 

the  bend  of  the  knee  or  lower  than  the  upper  margin  of  the  malleolus 
internus,  unless  the  fracture  should  be  near  one  of  these  extremities; 
and  in  case  it  does  extend  lower,  the  same  precautions  must  be  taken 
to  protect  the  malleolus  internus  from  pressure.  Whichever  also  of 
the  materials  is  employed,  the  splint  never  ought  to  be  applied  directly 
to  the  skin,  but  a  thin  pad  made  of  a  few  layers  of  cotton  sheeting 
covered  with  cotton  cloth  must  be  laid  underneath. 

It  is  seldom  that  I  have  found  it  necessary  or  useful  to  apply  any 
bandages  directly  to  the  skin,  whatever  form  of  apparatus  has  been 


460  FRACTURES    OF    THE    TIBIA    AND    FIBULA. 

employed,  but  in  certain  cases  of  compound  fractures,  where  dressings 
have  been  applied  which  needed  support  and  protection,  a  bandage 
has  been  of  service.  The  roller,  unless  the  patient  is  a  child,  whose 
limb  can  be  easily  lifted  and  managed,  is  always  objectionable;  but 
the  many-tailed  bandage,  made  of  narrow  strips  of  cloth,  laid  upon 
each  other,  as  we  have  already  described  in  our  general  remarks 
upon  bandages,  &c.,  is  occasionally  useful. 

Having  made  these  preparations,  we  proceed  to  flex  the  leg  to  a 
right  angle  with  the  thigh,  and  by  the  hands  make  extension  and 
counter-extension  as  much  as  the  patient  will  bear,  or  as  much  as 
may  be  necessary  to  restore  the  fragments  to  place,  in  case  this 
restoration  is  found  to  be  practicable.  If  the  fracture  is  compound, 
and  the  point  of  bone  protrudes  through  the  skin,  it  is  often  dilRcult 
to  replace  it.  That  is,  we  are  unable  to  overcome  the  action  of  the 
muscles  sufficiently  to  make  the  limb  of  its  natural  length,  and  for 
this  reason,  mainly,  we  are  unable  to  get  the  point  of  bone  beneath 
the  skin.  If  we  cannot  then  "set"  the  bone,  or  bring  the  ends  into 
apposition,  and  this  will  be  the  fact  pretty  often,  we  still  have  no  apology 
generally  for  leaving  the  bone  outside  of  the  skin.  First,  an  attempt 
must  be  made  to  accomplish  this  reduction  by  pulling  aside  the  skin 
with  the  fingers,  or  with  a  blunt  hook.  This  simple  procedure  has 
often  succeeded  with  me  in  a  moment,  when  others  have  been  trying 
in  vain  to  accomplish  the  same  end  by  pulling  upon  the  limb.  If 
this  fails,  then  the  skin  should  be  cut  sufficiently  to  allow  the  bone  to 
retire,  or  if  the  point  is  sharp,  and  especially  if  it  is  stripped  of  its 
periosteum,  it  may  be  sawn  off.  Kesecting  thus  the  end  of  an  oblique 
fragment  does  not  generally  affect  in  any  degree  the  length  of  the 
limb,  or  interfere  with  a  prompt  and  perfect  cure,  but,  on  the  contrary, 
it  often  is  advantageous  in  every  point  of  view. 

Having  restored  the  fragments  to  their  places  as  well  as  we  may, 
the  limb  is  laid  carefully  on  its  outside  upon  the  long  wooden  splint. 
tWe  shall  now  find  it  necessary  generally  to  add  two  or  three  thin 
pads,  in  order  to  supply  vacancies  which  we  have  not  perfectly  pro- 
vided for  in  the  preparation  of  the  splint.  Generally  we  shall  also 
see  the  necessity  of  placing  a  pretty  thick  pad  under  the  outer  margin 
of  the  foot  or  toes,  so  as  to  bring  the  great  toe  in  line  with  the  inner 
edge  of  the  patella  and  spine  of  the  tibia.  The  other  side  splint  is 
now  laid  along  the  inner  or  tibial  side  of  the  limb,  and  with  successive 
turns  of  a  roller,  or  with  a  number  of  narrow  and  separate  strips  of 
cloth,  the  whole  are  bound  together,  and  the  limb  is  left  to  repose 
upon  its  outer  side. 

The  patient  may,  if  necessary,  lie  upon  his  back,  but  it  is  better 
that  he  should  be  turned  a  little  toward  the  side  of  the  broken  limb. 
The  danger  of  twisting  the  fragments  upon  each  other  is  lessened  by 
lying  upon  the  same  side  with  the  broken  limb,  but  I  have  frequently 
permitted  patients  to  lie  upon  their  backs,  and  found  no  such  result. 
If  the  long  under  splint  extends  a  little  way  upon  the  thigh,  and  is 
well  fastened  to  the  thigh,  the  twist  cannot  very  well  occur. 

By  adopting  this  general  plan  of  treatment  we  avoid  all  chances  of 
gangrene  or  swelling  of  the  foot  from  excessive  ligation,  and  it  is  to 


FRACTURES    OF    THE    TIBIA    AND    FIBULA.  461 

these  accidents,  especially,  that  the  remarks  of  Dr.  Norris,  already 
quoted,  are  applicable.  The  larger  size  and  irregular  form  of  the 
bones  of  the  leg,  the  small  amount  of  muscular  tissue  covering  them, 
especially  near  the  articulations,  the  severity  of  the  injuries  to  which 
they  are  liable,  with  their  remoteness  from  the  centre  of  circulation — 
these  circumstances  altogether,  render  them  exceedingly  exposed  to 
injury  from  the  too  great  or  unequal  pressure  of  splints  or  of  bandages ; 
and  it  has  often  occurred  to  myself,  as  it  has  to  Dr.  Norris,  to  find  the 
skin  vesicated,  or  even  ulcerated  and  sloughing,  when  the  patients  are 
first  admitted  to  the  hospital;  a  condition  which,  in  nine  cases  out  of 
ten,  is  due  to  the  mal-adjustment  of  the  splints,  or  to  the  tightness  of 
the  bandages. 

If  bandages  are  used  under  the  splints,  and  next  to  the  skin,  they 
must  be  applied  very  moderately  tight,  and  loosened  or  cut  as  the 
swelling  augments;  and,  from  the  first  day  of  treatment  to  the  last, 
the  surgeon  must  be  careful  to  loosen  or  tighten  the  dressings  when 
the  swelling  increases  or  subsides,  just  as  the  prudent  boatman  trims 
his  sails  to  the  rising  and  falling  breeze. 

Dr.  Krackowitzer  presented  to  the  New  York  Pathological  Society, 
June  10,  1863,  a  leg  which  he  had  amputated  for  gangrene  occasioned 
by  tight  bandages.  A  boy,  five  years  old,  sustained  an  injury  of  the 
ankle-joint,  which  his  medical  attendant  pronounced  a  fracture  of  the 
fibula,  and  for  which  he  applied  only  a  tight  bandage.  The  child 
suffered  a  good  deal  after  the  bandage  was  applied,  and  the  following 
morning  the  toes  were  blue,  but  the  doctor  paid  no  attention  to  this 
circumstance.  The  pain  subsided  on  the  third  day,  and  on  the  fourth 
the  bandages  were  removed,  and  the  limb  found  to  be  gangrenous. 

The  specimen  showed  that  the  fibula  was  not  broken,  but  that  there 
was  a  fissure  or  crack  in  the  lower  part  of  the  shaft  of  the  tibia.^ 

The  following  case,  which  has  been  communicated  to  me  by  Dr. 
Fuller,  of  Wyoming,  N.  Y.,  with  permission  to  make  such  use  of  it 
as  I  choose,  is  sufficiently  pertinent  for  the  instruction  of  others,  and 
deserves  a  public  record  : — 

A  man,  get.  71,  fell  from  a  tree,  striking  upon  his  foot,  Aug.  27, 
1855,  producing  a  backward  dislocation  of  both  the  tibia  and  fibula 
upon  the  os  calcis,  and  also  a  fracture  of  both  bones  of  the  leg  a  few 
inches  above  the  ankle. 

An  empiric  took  charge  of  this  unfortunate  man,  and  immediately 
applied  lateral  splints  and  a  firm  roller  from  the  toes  to  the  knee. 
Notwithstanding  the  remonstrances  and  prayers  of  the  patient  to  have 
the  bandage  loosened,  it  was  kept  on  until  the  ninth  day,  when  the 
doctor  cut  the  bandage  upon  the  top  of  the  foot,  and  it  was  found 
vesicated.  Ignorant,  however,  as  to  the  cause  of  this  vesication,  and 
of  the  danger  which  it  threatened,  he  omitted  to  loosen  the  remainder 
of  the  bandages,  and  the  limb  was  left  in  this  condition  until  the 
twenty-third  day,  when  Dr.  Fuller  being  called,  and  having  removed 
all  the  dressings,  found  the  integuments  covering  the  whole  foot  dead 
and  dried  down  to  the  bones.     The  dislocations  had  not  been  reduced. 

'  Krackowitzer,  Amer.  Med.  Times,  Xov.  7,  1863. 


462  FEACTURES    OF    THE    TIBIA    AND    FIBULA. 

Soon  nfter  this  the  limb  became  oedematous,  and  on  the  twenty-seventh 
of  October  the  leg  was  amputated  by  Dr.  Barrett,  of  Le  Roy ;  from 
which  time  the  patient  recovered  rapidly. 

But  it  is  to  the  advantages  of  the  posture  recommended  by  Pott 
that  I  wish  especially  to  direct  attention.  The  position  hitherto  gene- 
rally preferred  by  surgeons  has  been  that  in  which  the  limb  rests 
upon  its  back,  either  in  a  box  or  upon  a  double-inclined  plane  ;  but  all 
of  the  examples  of  ulcers  upon  the  heel  which  I  have  seen  have  been 
after  treatment  in  this  position.  Indeed,  it  is  almost  impossible  for 
this  accident  to  happen  in  any  other  way,  and  it  has  therefore  never 
occurred  to  me  to  see  it  in  cases  treated  by  Pott's  method.  It  is  true 
that,  with  great  care,  such  a  result  might  generally  be  prevented  while 
the  leg  is  resting  upon  its  calf,  yet  experience  shows  that  it  is  by  no 
means  easy  to  avoid  it  always.  And  if,  in  our  anxiety  to  obviate  this 
evil,  we  place  pads  underneath  the  tendo  A  chill  is,  above  the  heel,  we 
incur  the  risk  of  pressing  the  fragments  forwards,  and  of  compelling 
them  to  unite  with  the  whole  lower  part  of  the  leg  inclined  backwards. 
I  have  mentioned  already  that  this  has  happened,  in  cases  that  have 
subsequently  come  under  my  observation,  no  less  than  seven  times, 
while  an  attempt  to  correct  this  fault  by  placing  the  support  under 
the  heel  has  either  produced  ulcers  of  the  heel,  or  driven  the  lower 
part  of  the  limb  in  the  opposite  direction. 

The  same  thing — that  is,  a  deviation  backwards  or  forwards — might 
happen  in  any  posture,  but  I  am  sure  it  is  much  less  liable  to  in  Pott's 
position  than  in  any  other. 

Then,  again,  a  twist  or  rotation  of  the  lower  fragment  is  more  liable 
to  take  place  when  the  toes  point  upwards,  and  the  limb  rests  upon  the 
calf  and  heel,  than  when  the  limb  reposes  upon  its  side.  In  the  one 
case  it  is  resting  upon  a  narrow  surface,  with  the  whole  weight  of  the 
foot  disposing  it  to  either  eversion  or  inversion,  while  in  the  other  it 
lies  upon  a  broad  surface,  with  the  foot  entirely  at  rest,  and  demanding 
no  extraordinary  support. 

In  short,  Pott's  position  is  less  irksome  to  the  patient,  and  vastly  less 
troublesome  to  the  surgeon.  Ugly  and  crooked  limbs  are  sometimes 
inevitable,  and  they  are  often  the  consequences  of  unskilful  manage- 
ment or  of  inattention  on  the  part  of  the  surgeon ;  but,  other  things 
being  equal,  the  best  legs  have,  in  my  experience,  come  out  of  Pott's 
position,  and  the  worst  out  of  the  double-inclined  plane  and  the  box. 

As  to  the  tendency  of  the  upper  fragment  to  rise  at  the  point 
of  fracture,  it  depends,  no  doubt,  upon  the  usual  direction  of  the 
fracture,  and  the  action  of  the  muscles  both  in  front  and  behind  ;  so 
far  as  the  former  circumstance  is  the  cause — that  is,  the  direction  of 
the  line  of  fracture — no  position  is  sufficient  to  remedy  it;  and  in  rela- 
tion to  the  action  of  the  muscles,  the  indications  are  as  easily  and 
naturally  fulfilled  with  the  limb  upon  its  side  as  upon  its  back.  Gene- 
rally the  leg  needs  to  be  flexed  upon  the  thigh;  but  if  the  fracture  is 
high  up,  and  its  direction  is  obliquely  downwards  and  forwards,  it 
must  be  made  nearly  or  quite  straight,  so  as  to  overcome  the  action 
of  the  anterior  muscles  of  the  thigh,  acting,  through  the  ligamentum 
patellas,  upon  the  upper  fragment.     The  simple  rule  which  I  recom- 


FRACTURES    OF    THE    TIBIA    AND    FIBULA.  463 

mend  and  adopt  is,  to  flex  or  extend  the  limb  more  or  less  until  it  is 
ascertained  in  what  position  the  apposition  of  the  fragments  is  most 
complete.  i 

As  has  already  been  intimated,  I  have  of  late  less  frequently  re- 
sorted to  the  method  of  treatment  just  described,  and  have  substituted 
the  following : — 

The  fragments  being  adjusted,  two  lateral  splints  of  leather,  long 
enough  to  extend  from  near  the  knee-joint  to  the  metatarso-phalangeal 
articulations,  and  wide  enough  to  nearly  encircle  the  limb,  are  moulded 
to  the  limb  on  each  side,  and  secured  in  place  by  successive  turns  of 
the  roller.  When  the  skin  is  delicate  or  tender,  these  should  be  un- 
derlaid with  a  thin  sheet  of  cotton  wadding  or  of  patent  lint.  A  soft 
woollen  cloth  may  answer  the  purpose  equally  well.  A  rack  is  then 
placed  over  the  limb,  such  as  will  be  seen  figured  for  the  suspension 
of  the  limb  when  dressed  with  plaster  of  Paris,  and  from  this  the  leg 
is  suspended.  The  objects  to  be  attained  by  the  suspension  are  three- 
fold :  first,  to  avoid  the  danger  of  pressure  upon  the  heel,  and  conse- 
quent ulceration;  second,  to  prevent  that  driving  down  of  the  upper 
fragment  upon  the  lower  which  constantly  ensues  when  the  foot  rests 
upon  the  bed  or  in  a  box  which  is  immovable;  third,  to  obviate 
movement  of  the  fragments  upon  each  other  when  the  patient  sits  up 
or  lies  down  in  bed.  This  movement,  I  observe,  is  peculiar.  It  is  not 
simply  a  motion  of  the  fragments  upon  each  other,  as  upon  a  pivot  at 
the  point  of  fracture,  which  motion  seldom  interferes  materially  with 
consolidation,  but  it  is  a  rising  and  falling  of  the  upper  fragment,  or 
a  motion  to  and  from  of  the  fragments,  and  also  a  riding  motion  ; 
either  of  which  latter  movements  necessarily  delays  or  defeats  bony 
union.  It  is  because  these  motions  are  generally  permitted  to  occur 
in  the  usual  modes  of  dressing  these  fractures,  more  than  for  any  other 
reasons,  that  union  is  so  often  delayed  in  the  case  of  these  bones.  In 
my  own  practice,  when  this  plan  of  suspension  is  enforced,  delay  never 
occurs,  but  nothing  is  more  common  than  for  me  to  meet  with  it  when 
other  surgeons  have  had  charge  of  the  limb,  and  the  suspension  has 
been  omitted. 

In  suspending  the  limb,  it  is  only  necessary  that  the  leg  should 
float  clear  of  the  bed;  and  I  think  it  worth  while  to  say  that  when 
leather  is  used  for  splints,  a  broad  oval  piece  of  leather  or  of  some  other 
firm  material  should  receive  the  limb  in  suspension,  rather  than  pieces 
of  bandage,  which  soon  become  cords,  and  press  unequally.  To  the 
sides  of  these  oval  pieces  bands  are  attached,  and  their  ends  tied  over 
the  top  of  the  rack.  One  must  be  placed  under  the  knee  and  one 
under  the  ankle. 

If  the  fracture  is  above  the  middle  of  the  leg,  complete  quietude  of 
the  fragments  can  only  be  obtained  by  carrying  the  splints  and  the 
bandages  above  the  knee. 

I  have  already,  in  my  remarks  on  the  treatment  of  fractures  in 
general,  declared  my  acceptance  of  the  so-called  "  immovable  appa- 
ratus" in  the  treatment  of  certain  fractures  of  the  leg  below  the  knee, 
and  especially  of  the  plaster  of  Paris  dressings.  In  hospital  practice, 
where  these  dressings  can  be  applied  by  experts,  and  where  the  limb 


464  FEACTURES    OF    THE    TIBIA    AND    FIBULA. 

can  be  watched  daily  and  hourly,  most  or  all  of  the  dangers  incident 
to  this  form  of  dressing  may  be  avoided ;  but  even  here  I  have  occa- 
sionally seen,  from  a  little  too  much  delay  in  opening  the  dressings, 
serious  trouble  ensue.  Its  most  devoted  advocates,  Seutin,  Velpeau, 
and  others,  have  never  denied  the  necessity  of  caution  in  its  use. 
To-day  I  hear  of  a  surgeon  in  a  neighboring  State  who  has  been  pro- 
secuted for  damages  in  consequence  of  the  death  of  the  limb  caused, 
as  is  alleged,  'by  this  form  of  dressing.  On  the  other  hand,  when 
applied  judiciously,  even  immediately  after  the  receipt  of  the  injury, 
and  when  carefully  watched  and  opened  freely  on  the  first  notice  of 
danger,  it  has,  in  my  wards,  and  in  the  hands  of  my  excellent  house 
surgeons,  often  served  its  purpose  more  completely  than  any  other 
apparatus  or  splints  I  have  ever  seen  employed.  It  has  steadied 
and  supported  all  parts  of  the  limb  more  completely,  and  permitted 
it  to  be  handled  more  freely,  than  anything  else  could  do.  In  simple 
fractures  patients  have  been  permitted  to  walk  about  upon  crutches 
after  the  third  or  fourth  day,  and  generally  no  harm  has  resulted.  In 
one  case,  however,  I  believe  this  liberty  caused  a  serious  delay  in  the 
union ;  and  in  another  an  abscess  resulted,  which  would  have  been 
avoided  if  he  had  remained  .in  bed.  For  myself,  I  do  not  think  any 
great  advantage  is  derived  from  allowing  the  patient  to  leave  his  bed, 
and  it  is  certainly  attended  with  some  additional  dangers;  I  therefore 
seldom  recommend  it. 

But  it  is  in  the  management  of  compound  fractures  of  the  leg  that 
I  have  of  late  seen  the  greatest  advantage  in  this  mode  of  dressing; 
and  it  was  in  precisely  these  cases  that  I  formerly  believed  the  im- 
movable apparatus  most  objectionable.  I  do  not  wish  to  retract  any- 
thing I  have  heretofore  said  as  to  its  dangers,  but  I  have  not  until 
lately  fully  appreciated  to  what  a  degree  these  dangers  might  be 
.overcome  by  skill  and  attention. 

The  following  careful  description  of  the  proper  mode  of  applying 
■plaster  of  Paris  bandages  in  fractures  of  the  leg  has  been  prepared  at 
my  rfequest  by  Dr.  S.  B.  St.  John,  one  of  our  house  surgeons.  His 
large  experience  and  his  habits  of  accurate  observation  render  his 
statements  peculiarly  trustworthy. 

"  The  materials  necessary  are,  blanket  or  cotton  wadding,  blanket 
being  preferable,  and  plaster  of  Paris  bandages,  which  are  prepared 
by  rubbing  dry  plaster  into  the  meshes  of  a  bandage  of  coarse  tex- 
ture, and  rolling  it  up  so  as  to  make  it  convenient  of  application. 
(These  may  be  kept  ready  for  use  in  tin  cans.)  The  bones  having 
been  placed  in  position,  the  leg  is  placed  upon  the  blanket,  which  is 
cut  and  folded  neatly  around  it,  and  secured  by  a  few  pins.  The 
blanket  should  extend  from  the  base  of  the  toes  to  the  knee,  or  in 
case  of  fracture  above  the  middle  or  of  compound  fracture  at  any  point, 
a  few  inches  above  the  knee.  The  plaster  bandages  should  then  be 
immersed  in  hot  water,  to  which  a  little  salt  has  been  added  to  hasten 
the  setting,  and  while  in  the  water  they  may  be  gently  kneaded  to 
insure  moistening  of  every  part.  In  about  three  minutes,  or  when 
bubbles  of  air  cease  to  rise  from  them,  they  will  be  ready  for  use,  and 
should  be  taken  out  as  they  are  wanted,  and  gently  squeezed  to  get 


FRACTURES    OF    THE    TIBIA    AND    FIBULA.  465 

rid  of  superfluous  water.  They  are  then  to  be  applied  after  the  fashion 
of  an  ordinary  bandage,  over  the  blanket,  with  just  sufficient  firmness 
to  insure  a  complete  fit.  If,  at  any  revolution  of  the  bandage,  the 
plaster  is  seen  to  be  dry,  it  should  be  moistened  by  dipping  the  hand 
in  water  and  rubbing  it  over  the  dry  surface.  Extra  turns  of  the 
bandage  should  be  taken  at  the  places  where  it  is  necessary  to  secure 
extra  strength  to  the  splint.  Three  or  four  bandages  (six  yards  long) 
are  usually  sufficient  to  make  a  firm  splint.  The  splint  will  usually 
be  sufficiently  pliable  just  after  its  application  to  allow  of  rectification 
of  any  faulty  position  which  may  have  occurred  during  its  application. 
It  should  then  be  kept  in  shape  by  the  pressure  of  the  hands  until  it 
hardens,  which  will  be  in  from  ten  to  thirty  minutes,  according  to  the 
freshness  of 'the  plaster  and  texture  of  the  bandages  used.  If,  for  any 
reason,  it  is  desirable  to  cut  the  splint  so  as  to  admit  of  its  removal, 
or  to  cut  a  fenestra  through  which  to  observe  any  part,  this  may  best 
be  done  before  the  plaster  becomes  perfectly  dry,  say  in  from  two  to 
five  hours  after  its  application,  depending  upon  the  quality  and  fresh- 
ness of  the  plaster.  It  will  then  cut  like  hard  cheese,  and  a  stout 
sharp  knife  should  be  used.  In  splitting  a  splint  anteriorly,  it  is  con- 
venient at  the  same  time  to  take  out  a  piece  about  an  inch  wide,  by 
making  two  parallel  cuts  one  inch  apart,  one  on  either  side  of  the  me- 
dian line,  extending  nearly  through  to  the  blanket,  and  then  by  raising 
the  strip  at  the  upper  edge,  and  cutting  on  either  side  alternately,  the 
section  may  be  completed,  and  the  central  slip  removed  without 
danger  of  cutting  through  the  blanket  and  wounding  the  patient. 
The  blanket  may  then  be  cut  with  scissors  and  the  splint  sprung  off 
to  examine  the  limb,  if  necessary.  "When  replaced,  a  bandage  should 
be  applied  over  it.  If  it  should  be  necessary  to  cut  a  splint  which 
has  already  become  dry,  and  cuts  with  great  difficulty,  it  may  be 
softened  with  hot  water,  applied  by  a  sponge  in  the  track  of  the  pro- 
posed section  for  ten  or  fifteen  minutes. 

"  If  it  is  necessary  to  cut  such  a  large  fenestra  that  only  a  small  strip 
of  the  splint  would  be  left  connecting  its  upper  and  lower  portions,  it 
is  better  to  adopt  a  different  plan  of  application.  For  this  it  is  neces- 
sary to  have  a  solution  of  plaster  of  Paris  in  water  of  the  consistency 
of  cream.  A  piece  of  blanket  is  then  cut  long  enough  to  reach  from 
the  toes  to  the  top  of  the  proposed  splint,  ,and  about  fifteen  inches 
wide.  This  is  to  be  thoroughly  soaked  in  the  solution,  and  folded 
several  times  so  as  to  be  about  two  or  three  inches  wide  when  folded. 
This  is  to  be  applied  along  that  part  of  the  limb  which  it  is  not 
necessary  to  keep  under  observation  (if  convenient,  along  its  posterior 
aspect),  and  it  is  then  to  be  secured  in  position  by  circular  turns  of 
the  plaster  bandage  above  and  below  the  portion  to  be  left  exposed. 
Whenever  a  plaster  apparatus  extends  above  the  knee,  and  it  is  pro- 
posed to  sling  the  leg  from  a  cradle,  the  leg  should  be  flexed  slightly 
upon  the  thigh,  so  that  it  may  be  swung  horizontally.  Any  portion 
of  a  plaster  splint  exposed  to  the  moisture  of  discharges  or  of  water 
used  in  dressing,  should  be  carefully  protected  by  oil  silk  and  cotton 
wadding. 

"In  cases  where  not  much  swelling  is  anticipated,  blanket  is  pre- 


466 


FEACTUKES    OF    THE    TIBIA    AND    FIBULA. 


ferable  to  cotton  wadding,  as  an  elastic  medium  between  the  splint  and 
skin,  because  it  is  of  more  even  thickness  and  retains  its  place  better 
when  the  splint  is  removed,  but  cotton  answers  better  when  much 
swelling  is  anticipated,  as  being  more  elastic." 

The  accompanying  illustration  has  also  been  made  for  me  by  Dr. 
St.  John,  and  furnishes  a  faithful  picture  of  one  of  the  many  similar 
cases  now  under  treatment  by  this  method  at  Bellevue  Hospital. 

Fig.  206. 


Plaster  of  Paris  dressing,  and  suspension. 

There  are  a  few  cases  in  which  a  very  much  better  position  of  the 
fragments  can  be  secured  by  placing  the  patient  under  the  influence 
of  an  anesthetic,  and  by  applying  the  dressing  during  complete  an- 
aesthesia. But  the  surgeon  needs  to  be  warned  of  two  things  in  this 
connection :  first,  that  just  as  much  harm  can  be  done  to  the  soft  parts 
by  violent  wrenching  and  pushing  when  he  is  insensible  as  when  he 
is  fully  conscious;  second,  that  while  the  patient  is  passing  under  the 
influence  of  an  anaesthetic  he  is  liable  to  violent  muscular  spasms, 
which  may  do  serious  injury. 

In  such  few  cases  as  demand  or  warrant  a  resort  to  extension  and 
counter-extension,  a  double-inclined  plane  furnishes  a  convenient  mode 
for  its  accomplishment ;  but  it  is  only  occasionally  that,  in  fractures 
of  the  leg,  permanent  extension  and  counter-extension  can  be  em- 
ployed ;  an  assertion  which,  however  much  it  may  excite  surprise, 
experience  will  prove  true.  If  the  fracture  is  near  the  middle  of  the 
leg,  quite  remote  from  the  points  upon  which  the  appliances  for  ex- 
tension, &c.,  are  to  be  made  fast,  and  the  inflammation  is  moderate, 
something  may  be  done  in  this  way ;  but  when  the  point  of  fracture 
approaches  the  ankle-joint,  as  it  actually  does  in  a  great  majority  of 
cases,  a  gaiter,  made  of  any  material  whatever,  if  it  has  sufficient  firm- 
ness to  overcome  completely  the  action  of  the  muscles,  will  inevitably 
cause  congestion  and  swelling,  accompanied  sooner  or  later  with  great 
pain  and  with  ulcerations,  and  simply  because  the  extension  is  made 
directly  upon  parts  already  tender  and  inflamed  from  the  accident 
itself;  and  when  we  add  to  this  complete  and  violent  ligation  of  the 
limb  near  the  seat  of  fracture,  a  similar  ligation  of  the  limb  just  below 
the  knee,  for  the  purpose  of  making  counter-extension,  as  is  done  in 
what  is  known  among  American  surgeons  as  "  Hutchinson's  splint,"^ 

'  Elements  of  Surgery,  by  John  Syng  Dorsey,  vol.  i.  p.  181.     Philadelphia,  1813. 


FRACTURES    OF    THE    TIBIA    AND    FIBULA. 


467 


we  are  prepared  to  understand  bow  the  worst  consequences  may  ensue. 
I  have  once  seen,  when  this  abominable  apparatus  had  been  used, 
a  complete  ring  of  ulceration  below  the  knee,  and  another  as  complete 
around  the  foot  and  ankle.  The  limb  was  twice  girdled,  and  yet  the 
surgeon  thought  he  was  performing  a  duty  for  tlie  omission  of  which 
he  would  scarcely  have  been  regarded  as  excusable. 


Fiff.  207 


I 


James  Hutchinson's  splint  for  extension,  etc.,  in  fractures  of  the  leg.     (From  Gibson.) 

Jarvis's  adjuster,  a  still  more  mischievous,  inasmuch  as  it  is  a  more 
powerful  instrument,  operating  in  a  similar  manner,_  has  been  pro- 
ductive of  like  consequences  ;  but  Jarvis's  adjuster  is  liable  to  the 
additional  objection  that  by  its  great  weight  it  drags  off  the  limb, 
turning  the  toes  outwards,  an  objection  which  no  care  or  diligence  can 
generally  overcome. 

I  could  wish  that  neither  of  these  appliances  would  ever  again  be 
impressed  into  the  service  of  broken  legs. 

Neill,  of  Philadelphia,  and  others  have  sought  to  overcome  some  of 
the  difficulties  in  the  way  of  making  extension  in  fractures  of  the 

Fis:.  208. 


John  Neill's  apparatus  for  fractures  of  the  leg  requiring  extension  and  counter-extension. 

legs,  by  substituting  adhesive  plaster  for  the  usual  extending  or 
counter-extending  bands. 

Says  Dr.  Neill:  "  For  simple  fractures  of  both  bones  of  the  leg,  at- 
tended with  shortening  and  deformity  not  easily  overcome,  the  limb 
should  be  placed  in  a  long  fracture-box  with  sides  extending  as  high 
as  the  middle  of  the  thigh,  and  a  pillow  should  be  used  for  compresses. 

"  The  counter-extension  is  made  by  strips  of  adhesive  plaster,  one 
inch  and  a  half  in  breadth,  secured  on  each  side  of  the  leg  below  the 


468 


FRACTURES    OF    THE    TIBIA    AND    FIBULA. 


knee,  and  above  the  seat  of  fracture,  by  narrower  strips  of  plaster 
applied  circularly.  The  end  of  the  counter-extending  strips  may  then 
be  secured  to  holes  in  the  upper  end  of  the  sides  of  the  fracture-box, 
by  which  the  line  of  the  counter-extension  is  rendered  nearly  parallel  with 
the  limb. 

"  The  extension  is  also  to  be  made  by  adhesive  strips,  in  a  mode 
which  is  now  well  known  and  understood.  The  ends  of  the  extending 
bands  may  be  fastened  to  the  foot-board  of  the  box."^ 

Dr.  Neill  further  remarks:  "  In  compound  fractures  of  the  leg,  short- 
ening and  deformity  are  often  difftcult  to  overcome,  as  is  well  known 

Fiff.  209. 


John  NeiU'g  apparatus  for  compound  fractures  of  the  leg. 

to  experienced  surgeons.  In  such  cases  we  may  wish  to  dress  the 
wounded  soft  parts,  and,  at  the  same  time,  maintain  a  certain  amount 
of  extension  and  counter-extension. 

"  This  can  be  readily  accomplished  by  having  the  sides  of  the  frac- 
ture-box sawed  in  two  parts  at  the  knee,  so  that  the  sides  of  the  box 
above  the  knee,  from  the  upper  ends  of  which  the  counter-extension 
is  made,  need  not  be  disturbed  during  the  dressing,  while  that  portion 
of  the  side  of  the  box  corresponding  to  the  leg  may  be  opened  at 


Y\s.  210. 


Gilbert's  Box  fob  Compound  Fbactckks  of  thk  Lro. 
1.  The  four  counter-extending  adhesive  strips,  as  if  encircling  the  knee  and  upper  part  of  leg.     2. 
The  two  extending  adhesive  strips  crossing  at  the  bottom  of  the  foot,  ready  to  be  applied  to  the  foot.     3. 
Tourniquet. 

pleasure,  without  diminishing  the  tension  of  the  extending  or  counter- 
extending  bands." 

In  compound  fractures  of  the  leg,  Dr.  Gilbert  recommends  a  modifi- 
cation of  the  common  fracture-box.  In  this  apparatus  the  foot-board 
is  omitted,  and  a  block  for  the  reception  of  the  frame  of  the  tourniquet 
is  substituted.     Each  side  of  the  box  consists  of  three  separate  seg- 

'  Philadelphia  Med.  Exam.,  vol.  xi.  p.  580,  1855. 


FKACTUEES    OF    THE    TIBIA    AND    FIBULA. 


469 


ments.  Of  these  the  upper  and  lower  are  permanently  screwed  to  the 
bottom-board,  and  the  central  one  is  attached  by  hinges.  By  this 
arrangement  there  is  full  access  to  the  wound,  which  may  be  dressed 
from  day  to  day  without  disturbing  the  extension  and  counter-exten- 
sion, maintained  by  the  permanently  attached  upper  and  lower  seg- 
ments. 

The  following  wood-cuts  are  intended  to  illustrate  an  apparatus 
invented  by  R.  0.  Crandall,  for  the  purpose  of  making  permanent 

Fiff.  211. 


Section  of  Crandall's  apparatus,  applied  to  the  limb  ;  showing  adhesive  plaster  counter-extending  bands 

and  gaiter  for  extension,  &c. 

Fior.  213. 


Crandall's  apparatus  complete.     The  counter-extending  straps  are  passed  over  a  block  of  wood  sup- 
ported above  the  knee,  to  prevent  their  pressure  upon  the  sides  of  the  knee. 

Fiff.  213. 


Posterior  view  of  the  lower  portion  of  Crandall's  apparatus. 

extension.  The  extension  is  represented  as  being  made  by  a  gaiter, 
but  Dr.  Crandall  leaves  it  to  the  choice  of  the  surgeon  whether  he 
shall  employ  the  gaiter  or  adhesive  strips.^ 

Without  intending  to  deny  to  these  contrivances  much  ingenuity 
and  considerable  practical  value,  I  am  far  from  conceding  that  they 
will  be  found  capable  of  overcoming  altogether  the  action  of  the  mus- 

>  Crandall,  Phil.  Med.  Journ.,  vol.  iv.  p.  193,  Jan.  185G  ;  also  Transac.  of  Med. 
Assoc,  of  Southern  and  Central  New  York,  ISoo,  pp.  81,  83. 


470  FRACTURES    OF    THE    TIBIA    AND    FIBULA. 

cles  where  the  ends  of  the  fragments  do  not  support  each  other.  Their 
mode  of  action  is  such  that  they  can  scarcely  do  more  than  to  steady 
the  limb,  and  if  they  operate  upon  the  fragments  at  all  in  the  direction 
of  their  axes,  it  must  be  only  in  the  most  inconsiderable  degree.  The 
adhesive  plasters  are  substituted  for  the  circular  knee  bands  and  the 
gaiters,  with  a  view  to  avoid  ligation ;  but  in  order  to  do  this  they 
must  not  encircle  the  limb,  but  only  be  laid  parallel  to  its  long  axis. 
The  leg  of  an  adult,  or  that  portion  to  which  the  adhesive  plasters 
can  be  applied,  supposing  the  fracture  to  be  exactly  at  the  centre, 
may  be  sixteen  inches,  that  is,  eight  inches  for  extension  and  eight  for 
counter-extension  ;  but  when  we  employ  the  same  means  for  extension 
in  fractures  of  the  thigh,  we  find  it  necessary  to  apply  the  strips  over 
the  whole  of  these  sixteen  inches,  the  entire  length  of  the  leg,  or  they 
will  not  hold.  It  will  be  apparent  also  that  we  cannot  use  even  the 
eight  inches  which  we  have,  for  the  purpose  of  argument,  allowed 
these  gentlemen  in  fractures  of  the  leg.  There  must  be  at  least  a 
space  of  eight  inches  between  the  ends  of  the  two  opposing  strips  in 
order  that  they  may  operate  at  all  upon  the  fragments;  indeed,  I  do 
not  believe  that  even  then  their  influence  would  reach  beyond  the 
skin  to  which  they  were  directly  applied  ;  but  if  a  space  of  eight  inches 
is  left,  only  four  remain  for  the  strips  at  either  end;  and  this  is  an 
amount  of  surface  wholly  insufficient  for  our  purpose.  What,  then, 
shall  we  do  when  the  fracture  is  near  one  of  the  extremities  of  the 
bone?  These  gentlemen  seem  to  have  forgotten,  moreover,  that  the 
whole  leg  is  tender,  and  that  the  skin  easily  vesicates.  In  short,  they 
have  not  seen  the  many  points  of  difference  between  the  application 
of  these  means  in  fractures  of  the  thigh  and  leg,  and  which,  while 
they  allow  us  to  accomplish  all  that  we  could  desire  with  the  one,  are 
of  little  or  no  use  in  the  other.  We  shall  then  always  come  to  the 
same  conclusion;  whatever  means  we  may  employ  to  make  permanent 
extension  in  fractures  of  the  leg,  we  must  either  fail  to  accomplish 
all  that  we  desire,  or  incur  the  hazards  incident  to  complete  and  firm 
ligation  of  the  limb;  and  if  the  preference  is  given  to  any  form  of 
apparatus  to  accomplish  these  ends,  it  must  be  to  some  form  of  the 
double-inclined  plane,  by  which  we  may  at  least  avoid  ligation  in  the 
upper  part  of  the  limb,  the  counter-extension  being  made  against  the 
under  surface  of  the  thigh  while  it  is  resting  upon  the  thigh  piece;  or 
to  one  of  the  long  straight  thigh-splints,  which  will  enable  us  to  make 
the  counter-exitension  from  the  thigh  and  perineum. 

If  a  double-inclined  plane  is  used,  I  prefer  either  a  plain  apparatus, 
such  as  we  have  already  described  as  in  use  for  fractures  of  the  thigh, 
constructed  of  boards,  joined  together  by  hinges  opposite  the  knee, 
and  with  an  upright  foot-board,  upon  which  a  carefully  arranged  and 
thick  cushion  has  been  placed,  or  the  more  elegant  double-inclined 
plane  of  Liston. 

In  using  Liston's  apparatus,  it  must  not  be  inferred  that  the  knee  is 
always  to  be  bent.  The  apparatus  is  designed  to  be  used  occasionally 
as  a  straight  splint;  and  there  will  be  found  many  cases  of  fractures 
of  the  legs  in  which  the  straight  position  will  be  most  suitable :  this 
is  especially  true  of  such  fractures  as,  occurring  just  below  the  knee_ 


FKACTURES    OF    THE    TIBIA    AND    FIBULA. 


471 


joint,  have  the  line  of  fracture  directed  obliquely  downwards  and  for- 
wards.    But  there  are  many  compound  fractures  which  demand  the 


Fi?.  214. 


Liston's  double-inclined  plane  ;  applied  to  the  leg  in  a  case  of  compound  fracture.     (From  Miller.) 

same  extended  position ;  and  in  nearly  all  cases  where  this  form  of 
apparatus  is  used  as  a  double-inclined  plane,  the  lower  end  of  the 
splint  should  be  elevated  so  that  the  heel  shall  not  be  much  below  the 
level  of  the  knee. 

Bauer's  wire  splints,  used  also  for  side  splints,  when  they  are  formed 
to  fit  the  limb  accurately,  possess  some  advantages  which  must  recom- 
mend them  to  the  attention  of  surgeons ;  but  neither  these  splints  nor 

Fig.  215. 


Louis  Bauer's  wire  splints  for  the  leg.' 

any  others,  however  accurately  fitted,  ought  to  be  applied  directly  to 
the  naked  skin.  They  require  always  the  interposition  of  a  well- 
padded  lining. 

Boxes  are  rarely  useful  except  in  certain  compound  fractures.  They 
are  heavy  and  awkward  machines,  which  prevent  the  patient  from 
moving  readily  in  bed  ;  or  which,  being  fixed,  if  he  does  move,  allow 
the  upper  fragmemt  only  to  descend,  or  to  move  upon  the  lower  as  a 
fixed  point.  If  used  at  all,  they  ought  generally  to  be  suspended  or 
made  to  move  on  a  suspended  railwaj'.     But,  however  they  are  ar- 

'  Bauer,  Buffalo  Medical  Journal,  April,  18.j7,  vol.  xii. 


472 


FRACTURES    OF    THE    TIBIA    AXD    FIBULA. 


ranged,  the  limb  is  a  great  part  of  the  time  concealed  from  sight,  and 
the  surgeon  is  prevented  from  making  use  of  such  means  to  rectify 


Fis:.  216. 


Swing  box  or  "  cradle."    (From  Skey.) 


deviations  in  the  line  of  the  bone  as  he  would  probably  have  other- 
wise employed. 

The  swing  invented  by  James  Salter,  of  London,  is  constructed  so 
as  to  allow  not  only  a  lateral  motion,  but  also  a  more  complete  motion 
in  the  direction  of  the  axis  of  the  limb,  by  which  the  danger  of  push- 


Fiff.  217. 


Salter's  cradle.     (From  Fergusson.) 


ing  the  fragments  upon  each  other  is  obviated.  This  is  accomplished 
by  the  rolling  of  two  pulley-wheels  upon  a  horizontal  bar.  The  case 
in  which  the  leg  rests  may  be  made  of  metal  or  of  wood,  and  the  frame 
of  iron,  for  the  sake  of  lightness  and  strength. 

Dr.  Hodgen,  of  St.  Louis,  suspends  the  box  over  a  pulley  placed 
transversely,  so  that  by  drawing  the  rope  to  the  right  or  to  the  left, 
the  box  may  be  turned  upon  either  side. 


FEACTUEES    OF    THE    TIBIA    AND    FIBULA. 


473 


Fig.  218. 


Fracture-box,  with  movable  sides. 


These  boxes  are  sometimes  filled  with  bran,  the  bran  being  closely 
packed  upon  all  sides  so  as  to  support  the  limb  uniformly  and  gently. 
This  method  of  treating  compound  fractures  of  the  leg  was  first  sug- 
gested by  J.  Rhea  Barton,  of  Phila- 
delphia,^ and  has  been  much  used  in 
the  Pennsylvania  Hospital;  and  lat- 
terly it  has  been  introduced  into  the 
Bellevue  and  New  York  City  Hospi- 
tals. It  possesses  the  advantage  of 
affording  a  perfect  protection  against 
flies  in  the  summer  season,  and  of 
absorbing  the  matter  as  it  escapes. 
Whenever  any  portion  of  it  becomes 
soiled  by  blood  or  pus,  it  may  be 
dipped  out  with  a  spoon,  and  its 
place  supplied  with  fresh  bran.  The  support  which  it  gives  to  the 
limb  is  also  uniform  without  being  at  any  time  excessive,  and  Dr. 
Coates  states  that  the  escape  of  blood  in  rapid  hemorrhages  has  been 
known  to  increase  the  bulk  of  the  bran  sufficiently  to  arrest  the 
bleeding  by  its  accumulated  pressure. 

In  whatever  position  the  leg  is  placed,  and  with  many  of  the  forms 
of  apparatus  which  we  have  enumerated,  it  will  be  found  necessary  to 
protect  the  limb  from  the  weight  of  the  bed- 
clothes by  some  contrivance  similar  to  that 
figured  in  the  accompanying  drawing;  or  by  a 
rack,  such  as  is  represented  for  suspending 
the  leg  when  leather  splints  or  the  immovable 
apparatus  is  employed, 

Malgaigne,  who  declares  that  every  surgeon 
knows  how  impossible  it  is,  in  an  immense 
majority  of  cases,  to  overcome  the  projection 
of  the  superior  fragment  when  the  limb  is  placed  in  the  extended 
position  (over  a  double-inclined  plane),  and  who  affirms  that  neither 
Pott's  position,  nor  Dupuytren's  modification  of  it,  will  do   much  if 


Fi?.  219. 


Wire  rack  for  fracture  of  lea 


Fiff.  220. 


Malgaigne's  apparatus  for  oblique  fractures  of  the  leg.     (From  Malgaigne.) 

any  better,  nor,  indeed,  that  Laugier's  *plan  of  cutting  the  teudo 
Achillis  possesses  in  this  respect  any  real  advantage,  concludes  at 

'  Barton,  Amer.  Journ.  of  Med.  Sci.,  vol.  xvi.  p.  31,  and  vol.  xix.  p.  515. 
31 


474 


FRACTUEES    OF    THE    TIBIA    AND    FIBULA. 


last  to  resort  to  a  new  and  really  ingenious  method,  the  value  of 
which,  also,  he  claims  to  have  already  fully  demonstrated.  His  appa- 
ratus consists  simply  of  a  steel  band  of  sufficient  size  to  encircle  three- 
fourths  of  the  limb,  at  the  two  extremities  of  which  are  two  horizontal 
mortises  through  which  a  band  is  passed,  and  which  may  be  buckled 
upon  itself  behind.  The  centre  of  the  metallic  arch,  in  front,  is 
penetrated  with  a  firm  metallic  screw,  terminating  in  a  very  sharp 
point,  and  which  is  moved  by  a  flat  thumb-piece. 

The  limb  being  laid  over  a  double-inclined  plane,  and  the  pads 
being  carefully  adjusted,  as  we  have  already  directed  when  speaking 
of  other  forms  of  apparatus,  and  the  limb  properly  extended,  the 
apparatus  of  Malgaigne  is  placed  over  the  limb,  with  the  sharp  point 
of  the  screw  resting  upon  the  upper  fragment,  a  few  lines  above  the 
Doint  of  fracture ;  and  at  the  same  moment  that  this  point  is  pressed 
firmly  down  to  the  bone,  the  fragments  being  held  together  by  an 
assistant,  the  strap  is  buckled  as  tightly  as  possible  under  the  splint. 
A  few  turns  of  the  screw  will  now  make  its  point  penetrate  more 
deeply  into  the  bone,  and  insure  the  most  complete  apposition  of  the 
broken  extremities.  "This  is  accomplished,"  says  Malgaigne,  "with 
very  little  pain  to  the  patient;"  and,  as  will  be  seen,  the  steel  arch 
effectually  prevents  any  ligation  of  the  limb.  I  cannot  say  that  the 
plan  receives  my  unqualified  approval ;  yet  I  have  employed  it  to 
advantage  in  some  cases  of  old,  ununited  fractures. 

Fiff.  221. 


Malgaigne's  apparatus  applied.    (From  Malgaigne.) 

Refradure  and  Resection  of  Crooked  Legs. — In  some  cases  of  extreme 
deformity  of  the  legs  consequent  upon  badly  united  fractures,  re- 
section of  the  bones  has  been  practised  with  more  or  less  success. 

The  first  case  of  which  I  have  seen  any  mention  made,  where  the 
bones  were  actually  resected,  is  reported  by  Charles  Parry,  of  Indian- 
apolis, Ind.  A  young  man,  set.  15,  having  broken  his  leg  near  its 
middle,  the  fragments  united,  from  some  cause,  nearly  at  right  angles 
with  each  other.  Some  years  afterwards,  on  the  15th  day  of  January, 
1838,  Dr.  Parry  operated,  by  removing  a  wedge-shaped  portion  from 
both  the  tibia  and  fibula.    The  recovery  was  tedious,  but  satisfactory.' 

'  Parry,  Amer.  Journ.  Med.  Sci.,  Aug.  1839,  p.  334. 


FRACTURES    OF    THE    TIBIA    AND    FIBULA.  475 

Mr.  Key,  of  London,  made  an  operation  of  this  kind  upon  a  gentle- 
man who  had  suffered  a  fracture  of  the  right  tibia  from  a  musket-ball. 
The  limb  was  nearly  useless,  since  he  could  only  bring  his  toes  to 
the  ground.  Mr.  Key  operated  in  Oct,  1838,  and  when  the  report  of 
the  case  was  made,  five  months  subsequently,  the  patient  was  doing 
well.^ 

In  Sept.  1840,  Dr.  Mutter,  of  Philadelphia,  made  a  similar  operation 
upon  a  patient,  whose  leg  was  shortened  three  inches  and  a  half,  and 
very  much  deformed ;  by  which  operation,  when  the  recovery  was 
complete,  the  shortening  was  considerably  reduced.^ 

Cases  may  occur  which  will  justify  a  resort  to  these  extreme  mea- 
sures, or  in  which  they  may  be  preferred  to  amputation  ;  but  an  ex- 
amination of  the  several  examples  reported  will  show  that  these  ope- 
rations are  not  unattended  with  danger  to  the  life  of  the  patient ; 
indeed,  in  this  respect,  amputation  has  greatly  the  advantage.  If, 
moreover,  the  surgeon  expects,  by  this  method,  to  lengthen  a  limb 
much,  where  it  is  merely  overlapped  and  shortened,  he  is,  I  am  certain, 
destined  to  disappointment,  at  least  in  all  cases  where  sufficient  time 
has  elapsed  for  the  bones  to  have  become  firmly  united.  I  have  myself 
several  times  refractured  a  bone;  and  I  have  several  times  met  with 
cases  of  old  fractures  newly  broken,  and  I  have  constantly  observed 
that  I  could  never,  in  the  end,  make  it  but  very  little  if  any  longer 
than  it  was  before  the  last  fracture.  The  muscles  had  contracted  to 
that  point,  and  their  contraction  would  not  be  overcome.  In  the  case 
reported  by  Miitter,  he  believed  that  he  stretched  the  muscles  two 
inches.  With  all  deference  for  the  skill  and  honesty  of  this  gentle- 
man, I  think  that  he  was  mistaken. 

If,  however,  the  object  of  the  operation  is  to  straighten  the  limb, 
then  no  doubt  it  may  be  sometimes  accomplished  ;  and  in  some  degree 
also  by  the  straightening  of  the  limb  the  shortening  may  be  over- 
come ;  but,  in  our  opinion,  such  procedures  ought  to  be  reserved  for 
extraordinary  circumstances. 

An  instructive  case  of  refracture  is  reported  by  Dr.  Horner,  of 
Philadelphia,  in  the  Medical  Examiner.  The  limb  had  been  broken 
eight  weeks,  and  was  quite  crooked,  but  was  not  very  firmly  united, 
and  Dr.  Horner  having  refractured  it,  was  able  at  once  to  restore  it 
to  a  nearly  straight  line.* 

'  Kc.y,  Amer.  Journ.  Med.  Sci.,  Aug.  1839,  p.  339,  from  Guy's  Hospital  Reports, 

April,  1839. 

2  Miitter,  Amor.  Journ.  Med.  Sci.,  April,  1842,  p.  359.  Three  similar  cases 
may  also  be  fouml  in  the  Oct.  No.  for  1841,  and  the  April  No.  for  1843  of  the  same 
journal,  in  which  the  operations  were  made  by  Portal,  of  Palermo.  Malgaigne 
mentions  two  other  examples. 

3  lloruer,  New  York  Journ.  Med.,  May,  1851,  p.  433. 


\ 

476  FRACTUEES    OF    THE    TARSAL    BONES. 


CHAPTER    XXXIII. 

FRACTUEES  OF  THE  TARSAL  BONES. 

Causes. — The  astragalus  is  generally  broken  by  a  fall  from  a  height, 
the  patient  having  struck  upon  the  bottom  of  the  foot.  Monahan,  in 
an  analysis  of  ten  cases,  found  it  had  been  broken  by  a  fall  upon  the 
foot  nine  times,^  and  onl}'-  once  by  a  crushing  accident. 

The  calcaneum  is  also  occasionally  broken  by  violent  lateral  pres- 
sure, but  much  more  often  by  a  fall  upon  the  foot,  or  rather  upon  the 
heel.  In  some  instances  both  heel-bones  have  been  broken  at  the 
same  moment ;  but  Malgaigne  has  collected  eight  cases  of  fracture  of 
this  bone  by  muscular  action,  as  in  jumping  upon  the  toes,  the  pos- 
terior portion  of  the  bone  being  thus  violently  acted  upon  by  the 
tendo  Achillis.  South,  in  his  Notes  to  Chelius,  has  mentioned  two 
other  cases,  one  of  Avhich  was  seen  by  Lawrence,  and  has  been  reported 
in  the  second  volume  of  the  Lancet.  This  person  had  received  the 
injury  by  jumping  off  a  stage-coach.  The  fragment  was  found  to  be 
drawn  upwards  slightly,  but  not  so  far  as  to  prevent  crepitus  when 
the  muscles  on  the  back  of  the  leg  were  relaxed.  The  other  example 
mentioned  by  South  is  a  cabinet  specimen  contained  in  the  museum 
of  St.  Bartholomew's  Hospital,  The  fracture  had  taken  place  just 
below  the  attachment  of  the  tendo  Achillis,  but  the  upper  fragment 
was  not  displaced.^  Mr.  Cooper  mentions  two  other  cases,  both  pro- 
duced by  violent  efforts  on  the  part  of  the  patients  to  sustain  them- 
selves when  falling.  In  one  of  these  the  fragment  was  immediately 
drawn  up  three  inches.^ 

The  other  bones  of  the  tarsus  are  generally  broken  by  crushing 
accidents,  such  as  the  fall  of  heavy  weights  upon  them,  by  the  passage 
of  loaded  vehicles,  &c. 

Pathology. — The  astragalus  often,  indeed  generally,  escapes  without 
injury  in  those  crushing  accidents  which  break  many  or  most  of  the 
other  bones  of  the  foot,  and,  as  we  have  seen,  it  is  seldom  broken 
except  when  the  patient  has  fallen  upon  the  bottom  of  his  foot ;  but 
at  the  same  moment,  the  foot  being  turned  forcibly  out  or  in,  a  dislo- 
cation of  the  tibia  takes  place,  and  the  fibula  is  broken.  In  nine  of 
the  cases  collected  by  Monahan,  one  or  the  other  of  these  forms  of 
dislocation  had  occurred,  in  eight  of  which  the  dislocation  was  com- 
pound.    The  direction  of  the  fracture  is  found  to  vary  greatly;  thus, 

'  Fracture  of  the  astragalus,  with  analysis  of  the  recorded  cases  of  this  injury. 
An  inaugural  thesis  presented  to  the  faculty  of  the  Buffalo  Med.  Col.,  March,  1858, 
by  Bernard  Monahan,  M.D. 

2  South,  Notes  to  Chelius's  Surgery,  vol.  i.  p.  639,  Amer.  ed. 

3  B.  Cooper's  ed.  of  Sir  Astley,  Amer.  ed.,  p.  311. 


FRACTURES    OF    THE    TARSAL    BONES.  477 

it  has  been  found  broken  in  its  length  antero-posteriorly,  in  its  breadth 
or  transversely,  and  in  one  instance  it  has  been  divided  nearly  hori- 
zontally, so  as  to  separate  the  upper  face  completely  from  the  lower. 
Sometimes  it  suffers  a  species  of  impaction,  the  fragments  being  actu- 
allv  driven  into  each  other;  at  other  times,  as  in  one  case  related 
by^Amesbury,  the  bone  may  be  split  without  the  occurrence  of  any 
displacement. 

The  calcaneum  also  may  be  broken  in  any  direction,  and  it  is  equally 
with  the  astragalus  liable  to  impaction,  by  which  its  vertical  diameter 
is  sensibly  diminished,  while  its  transverse  diameter  is  increased.  If 
the  fracture  is  a  consequence  of  muscular  action,  the  line  of  fracture  is 
always  posterior  to  the  astragalus,  and  in  some  cases  only  that  portion 
is  broken  off  to  which  the  tendo  Achillis  has  its  attachments.  It  may 
be  broken  also  vertically,  directly  underneath  the  astragalus,  in  which 
case  the  lateral  and  interosseous  ligaments  will  prevent  anything  more 
than  a  slight  displacement  of  the  posterior  fragment.  When  the 
fracture  takes  place  posterior  to  the  lateral  ligaments,  the  detached 
fragment  is  liable  to  be  drawn  very  far  from  the  body  of  the  bone,  even 
to  the  extent  of  four  or  five  inches,  and  possibly  farther  when  the  leg 
is  extended  upon  the  thigh  and  the  foot  flexed  upon  the  leg.  Con- 
stance relates  a  case  in  which  the  tuberosity,  having  been  broken  off 
by  a  direct  blow,  was  drawn  up  five  inches.^ 

Fractures  of  the  calcaneum  produced  by  contraction  of  the  sural 
muscles  are  generally  simple,  but  those  which  result  from  a  crushing 
of  the  bone  are  more  often  compound.  The  same  remark  is  applicable 
also  to  the  other  bones  of  the  tarsus,  the  fractures  of  which,  being 
only  produced  by  direct  blows,  are  generally  complicated  with  exter- 
nal wounds. 

Symptoms. — All  fractures  of  the  bones  of  the  tarsus  demand  especial 
care  in  their  diagnosis,  since  only  a  few  of  the  usual  signs  of  fracture 
are  in  a  majority  of  the  cases  presented.  The  explanation  of  this 
fact  will  be  found  in  the  number,  size,  and  strength  of  the  bones  of 
the  tarsus,  and  in  their  close  and  firm  union  by  ligaments,  by  which 
they  give  to  each  other  a  mutual  support,  so  that  the  fracture  of  a 
single  bone  does  not  necessarily  or  usually  result  in  displacement  or 
deformity,  and  even  crepitus  is  with  difl&culty  detected  ;  and  when  we 
consider,  moreover,  that  the  fracture  is  generally  produced  by  great 
violence,  directly  applied,  in  consequence  of  which  the  foot  in  most 
cases  becomes  rapidly  and  enormously  swollen,  we  shall  understand 
the  true  nature  of  the  difficulties  which  are  usually  presented  in  the 
way  of  an  accurate  diagnosis. 

Of  all  the  usual  signs  of  fracture,  crepitus  alone  is  pretty  generally 
present,  but  even  this  often  fails  to  tell  us  which  bone  is  broken,  and 
still  more  often  does  it  fail  to  inform  us  as  to  the  direction  and  extent 
of  the  bony  lesions. 

If  the  whole  or  a  portion  of  the  tuberosity  of  the  calcaneum  is  sepa- 
rated by  the  action  of  the  muscles,  and  the  fragment  is  drawn  up- 

'  Constance,  Amer.  Journ.  Med.  Sci.,  vol.  v.  p.  323,  Nov.  1839,  from  the  Midland 
Med.  and  Surg.  Reporter. 


478         FRACTURES  OF  THE  TARSAL  BONES. 

wards,  it  may  be  discovered  in  its  new  position,  and  the  heel  will  be 
flattened  or  shortened,  but  no  crepitus  can  be  felt  unless  the  fragments 
are  again  brought  in  contact. 

Treatment. — Not  any  of  the  fractures  of  the  tarsal  bones  in  them- 
selves demand  the  use  of  splints,  and  it  is  only  when  complicated  with 
a  dislocation  of  the  ankle  and  fracture  of  the  fibula  that  it  is  proper 
to  employ  apparatus  of  this  sort ;  certainly  the  exceptions  to  this  rule 
must  be  very  rare ;  so  that  our  practice  in  these  cases  will  be  confined 
chiefly  to  the  prevention  and  reduction  of  inflammation.  The  limb 
must  be  placed  in  the  most  easy  position,  and  cold  water  lotions  assidu- 
ously applied.  This  will  be  the  sum  of  the  treatment  demanded  during 
the  first  few  days  after  the  receipt  of  the  injury  in  probably  all  cases 
of  simple  fracture,  and  in  many  cases  of  compound  fracture. 

If  single  bones,  or  fragments  of  single  bones,  are  displaced  to  any 
considerable  extent,  and  there  is  an  external  wound  communicating 
with  the  fracture,  I  have  no  doubt  it  would  be  best  in  all  cases  to  re- 
move at  once  by  dissection  the  projecting  bone,  even  although  it  were 
possible,  or  perhaps  easy,  to  force  it  back  again  to  its  place,  as  has 
been  done  successfully  by  Ashhurst,  of  Philadelphia.^  The  same 
rule  I  would  apply  to  examples  of  fracture  uncomplicated  with  any 
external  wound,  if  the  fragments  were  very  much  displaced,  and  could 
not  by  the  application  of  moderate  force  be  replaced,  since  the  bone 
left  to  project  would  prevent  the  patient  from  ever  wearing  a  boot 
with  comfort,  and  would  entail  as  much  weakness  upon  the  limb  as 
would  be  likely  to  follow  from  its  complete  separation.  But  such 
cases  as  I  have  last  supposed  are  exceedingly  rare;  indeed,  I  have 
never  met  with  a  simple  fracture  of  a  tarsal  bone  accompanied  with 
displacement. 

Norris  has,  however,  reported  a  case  of  fracture  of  the  astragalus 
accompanied  with  displacement  of  about  one-half  of  the  bone,  but 
without  any  lesion  of  the  soft  parts.  This  was  in  the  person  of  a  man 
set.  30,  who  was  admitted  into  the  Pennsylvania  Hospital  on  the  26th 
of  Sept.  1831.  "An  hour  previous  to  admission,  while  descending  a 
ladder,  he  slipped  and  fell  in  such  a  manner  as  to  throw  the  entire 
weight  of  his  body  upon  the  outer  part  of  his  left  foot.  Upon  exami- 
nation, the  foot  was  found  to  be  turned  inwards  and  nearly  immovable. 
A  slight  depression  existed  immediately  below  the  lower  end  of  the 
tibia,  and  there  was  a  considerable  hard  and  rounded  projection  on  the 
outer  part  of  the  foot,  a  little  below  and  in  front  of  the  extremity  of 
the  fibula.  The  skin  covering  this  projection  was  reddened,  but  not 
excoriated.     There  was  no  fracture  of  either  bones  of  the  leg." 

These  appearances  led  Drs.  Norris  and  Barton,  under  whose  care 
the  patient  was  placed,  to  regard  the  accident  as  a  simple  luxation  of 
the  astragalus  forwards  and  outwards;  and  a  short  time  after  admis- 
sion efforts  were  made  to  reduce  it.  "This  was  done  after  relaxing  in 
as  great  a  degree  as  possible  the  muscles  of  the  leg,  by  fixing  the  knee, 
and  having  assistants  to  keep  up  extension,  by  seizing  the  heel  and 
front  part  of  the  foot ;  at  the  same  time  the  bone  being  pushed  inwards 

'  Ashhurst,  Amer.  Journ.  Med.  Sci.,  April,  1863. 


FEACTUKES    OF    THE    TARSAL    BONES.  479 

and  toward  the  joint  by  the  surgeon.  These  efforts  were  continued 
for  a  considerable  time,  but  bad  no  effect  in  changing  the  position  of 
the  bone. 

"Six  hours  afterwards,  Drs.  Huston  and  Harris  saw  the  patient  in 
consultation,  when  efforts  were  again  made  at  reduction,  which  not 
proving  more  effectual  than  in  the  first  trial,  the  excision  of  the  bone 
was  determined  on. 

"The  patient  being  properly  placed,  an  incision  was  made  through 
the  integuments,  parallel  with  the  course  of  the  tendons,  commencing 
a  short  distance  above  the  projection  on  the  foot,  and  extending  down 
far  enough  to  expose  fairly  the  astragalus  and  its  torn  ligaments. 
The  bone  was  then  seized  with  forceps,  and  easily  removed  after  the 
division  of  a  few  ligamentous  fibres  that  continued  to  connect  it  to 
the  adjoining  parts. 

"Very  little  hemorrhage  occurred,  two  small  vessels  only  requiring 
the  ligature. 

"After  removal,  it  was  discovered  that  about  one-half  of  the  surface 
which  plays  in  the  lower  end  of  the  tibia  had  been  fractured,  and 
remained  firmly  attached  to  the  extremity  of  that  bone,  and  as  it  was 
judged  that  the  efforts  to  remove  this  would  be  likely  to  produce  more 
injury  to  the  joint  than  would  arise  from  allowing  it  to  remain,  no 
attempt  was  made  to  extract  it. 

"The  joint  being  carefully  sponged  out,  the  sides  of  the  incision 
were  brought  accurately  together  by  means  of  sutures  and  adhesive 
straps,  after  which  simple  dressings  and  a  roller  were  applied,  and 
the  foot,  restored  to  its  natural  situation,  placed  in  a  fracture-box." 

Subsequently  that  portion  of  the  astragalus  which  was  permitted  to 
remain,  having  become  carious  and  loosened,  was  removed  also. 

The  case  continued  to  do  badly;  all  the  bones  of  the  tarsus,  and 
even  the  lower  ends  of  the  tibia  and  fibula,  becoming  eventually  cari- 
ous; and  on  the  27tli  of  March,  1853,  more  than  a  year  and  a  half 
after  the  receipt  of  the  injury,  the  leg  was  amputated ;  but  no  healthy 
action  ensued,  and  the  patient  soon  died.^ 

The  result  of  this  case  can  scarcelv  be  regarded  as  having  settled 
anything  in  reference  to  the  value  of  the  procedure  which  I  have 
recommended.  For  reasons  which  seemed  satisfactory  to  the  sur- 
geons who  made  the  operation,  only  one-half  of  the  broken  bone  was 
removed ;  whether  the  result  would  have  been  different  if  the  whole 
had  been  at  once  taken  away,  we  cannot  now  determine.  I  have 
related  it,  however,  as  the  only  example  of  a  simple  fracture  with 
displacement  which  I  have  been  able  to  find  upon  record ;  and  in  this 
case,  several  surgeons  of  merited  distinction  concurred  in  the  opinion 
that  the  protruding  fragment  ought  to  be  removed. 

A  fracture  of  the  posterior  portion  of  the  calcaneum,  especially  when 
it  has  been  produced  by  muscular  action,  constitutes  an  exception  to 
fractures  of  the  tarsal  bones  generally,  and  demands  usually  that 
apparatus  of  some  kind  should  be  employed  in  its  treatment. 

In  order  to  replace  the  posterior  fragment  when  displaced,  or  to 

'  Norris,  Amer.  Joiirn.  Med.  Sci.,  vol.  xx.  p.  379. 


480 


FRACTUEES    OF    THE    TARSAL    BONES. 


Fiff.  232. 


maintain  it  in  apposition  until  a  bony  union  is  accomplished,  it  will 
be  necessary  to  shorten  the  gastrocnemii  by  flexing  the  leg  upon  the 
thigh  and  extending  the  foot  upon  the  leg.  But  to  retain  the  limb 
in  this  position  it  will  be  expedient  always  to  employ  apparatus.  A 
very  simple  contrivance,  however,  will  generally  answer  all  the  indi- 
cations. A  bandage,  padded  strap,  or  a  stuffed  collar  may  be  fastened 
about  the  thigh  just  above  the  knee,  and  made  fast  to  the  heel  of  a 
slipper  by  a  tape  (Fig.  222).  The  apparatus  is  the  same  which  has 
been  recommended  for  a  rupture  of  the  tendo  Achillis. 

In  addition  to  this,  the  limb  ought  to  be  covered  from  the  foot 
upwards  as  far  as  the  knee  with  a  snug  roller,  underneath  which,  on 

each  side  of  and  above  the  detached  frag- 
ment, ought  to  be  placed  suitable  com- 
presses, the  object  of  the  roller  being  to 
diminish  muscular  contraction,  and  the 
compresses  being  intended  to  retain  the 
detached  piece  in  contact  with  the  main 
body  of  the  bone.  Some  surgeons  have 
not  found  it  necessary  to  flex  the  leg  upon 
the  thigh,  and  they  have  contented  them- 
selves with  extending  the  foot  upon  the 
leg,  and  confining  it  in  this  position  by 
a  splint  of  wood  or  gutta  percha  laid 
along  the  front  of  the  leg,  ankle,  and  foot. 
In  still  other  cases,  the  fragment  has 
shown  so  little  disposition  to  become 
displaced  as  to  render  no  precautions  of 
any  kind  necessary,  except  to  impose 
upon  the  patient  complete  quiet,  with  the 
limb  resting  upon  its  outside  and  flexed, 
as  in  Pott's  fracture  of  the  fibula. 

As  soon  as  the  inflammation  has  suffi- 
ciently subsided,  passive  motion  must 
be  given  to  the  ankle,  in  order  to  pre- 
vent, as  far  as  possible,  the  anchylosis 
which  is  an  almost  constant  result  of 
these  accidents.  Indeed,  the  patient  is 
fortunate  who  recovers  a  tolerable  use 
of  his  foot  after  the  lapse  of  many  months,  nor  can  he  be  assured 
that  the  inflammation  will  leave  these  bones  and  their  dense  fibrous 
envelopes  for  a  long  period,  and  that  it  may  not  result  in  caries  of 
more  or  less  of  the  tarsal  bones,  demanding  finally  amputation  of  the 
whole  foot. 

We  have  not  intended  to  speak  in  this  place  of  those  severer  acci- 
dents, accompanied  with  comminution  and  extensive  laceration,  which 
forbid  the  hope  of  saving  the  foot,  and  for  which  immediate  amputa- 
tion is  the  only  proper  resource,  but  which  constitute,  in  fact,  the  great 
majority  of  all  the  fractures  of  the  tarsal  bones. 


Apparatus  for  fracture  of  the   tube- 
rosity of  the  calcaneum. 


FBACTURES  OF  THE  METATARSAL  BONES.      481 


CHAPTER   XXXIV. 

FRACTURES  OF  THE  METATARSAL  BONES. 

These  bones  can  scarcely  be  broken  except  by  direct  blows,,  and 
the  great  majority  of  their  fractures  are  the  results  of  severe  crushing 
accidents,  such  as  render  amputation  sooner  or  later  necessary.  Of 
those  which  do  not  demand  amputation,  by  far  the  largest  proportion 
are  compound  fractures ;  of  which  class  the  following  example  will 
serve  as  an  illustration  : — 

A  man  in  the  employ  of  one  of  the  railroads  which  connect  with 
tbis  city  was  run  over  by  a  loaded  car  on  the  14th  of  June,  1856, 
crushing  his  right  arm  so  as  to  render  its  immediate  amputation 
necessary.  I  found  also  a  compound  comminuted  fracture  of  the 
fourth  metatarsal  bone  of  the  right  foot.  Considerable  hemorrhage 
occurred  from  the  wound,  but  this  ceased  spontaneously.  Cool  water 
dressings  were  diligently  applied,  without  splints  or  bandages,  and 
although  some  inflammation  and  suppuration  ensued,  the  parts  finally 
healed  over  and  the  fragments  united,  with  only  a  slight  backward 
displacement  at  the  seat  of  fracture. 

When  only  one  bone  is  broken,  the  displacement  is  usually  very 
trivial ;  but  when  several  are  broken,  it  may  be  considerable.  Mal- 
gaigne  relates  an  example  of  this  latter  accident  in  which,  the  three 
middle  bones  being  broken  by  the  wheel  of  a  carriage,  and  the  integu- 
ments being  badly  torn  and  bruised,  it  was  found  impossible  to  retain 
the  fragments  in  place.  The  patient  recovered,  and  was  able  to  place 
the  foot  well  to  the  ground,  but  the  proximal  fragments  continued  to 
project  upwards  upon  the  top  of  the  foot  to  such  a  degree  as  to  require 
a  special  shoe. 

In  a  majority  of  cases  the  direction  of  the  displacement  is  backwards 
or  upwards,  especially  when  the  middle  metatarsal  bones  are  the  sub- 
jects of  the  fracture. 

I  have  in  my  cabinet  a  second  metatarsal  bone  broken  obliquely 
near  its  middle,  with  only  a  very  slight  displacement  of  the  lower 
fragment  backwards ;  and  also  the  cast  of  a  bone  which  has  united 
with  an  enormous  backward  projection. 

In  one  instance  I  have  seen  the  metatarsal  bone  of  the  little  toe 
cut  in  two  with  an  axe,  and  the  fragments  united  in  about  thirty  days, 
but  with  the  lower  fragment  slightly  displaced  outwards. 

Delamotte  relates  a  case  also  in  which  the  first  four  metatarsal 
bones  were  cut  off,  and  complete  union  was  accomplished  on  the 
fortieth  day ;  at  the  end  of  two  months  the  patient  walked  without 
lameness. 

If  the  fragments  are  not  displaced,  nothing  is  required  except  that 


482       FRACTURES    OF    THE    PHALANGES    OF    THE    TOES. 

the  foot  shall  be  kept  at  rest,  and  the  inflammation  controlled  by 
suitable  means. 

In  case,  however,  a  displacement  exists,  it  ought  to  be  remedied,  if 
possible,  since,  if  only  very  slight,  it  may  become  the  source  of  a 
serious  annoyance.  If  the  fragments  project  upwards,  they  interfere 
with  the  wearing  of  a  boot,  and  if  they  sink  toward  the  sole,  the  skin 
beneath  is  liable  to  remain  constantly  tender,  and  the  patient  may 
thus  be  seriously  maimed  for  life. 

In  case  the  displacement  is  not  due  to  the  action  of  the  muscles, 
but  only  to  the  nature  and  direction  of  the  force  producing  the  frac- 
ture, or  to  entanglement  of  the  broken  ends,  and  it  is  likely  to  cause 
any  of  the  inconveniences  which  I  have  mentioned  if  permitted  to 
remain,  it  will  be  advisable  at  once  to  employ  considerable  force  in 
the  way  of  pressure,  or  to  elevate  the  fragments  through  an  opening 
previously  made  upon  the  dorsum  of  the  foot,  calling  to  our  aid  even 
the  saw  or  the  bone-cutters,  if  necessary.  After  which  the  fragments 
may  be  retained  in  place  by  carefully  applied  pasteboard  splints  and 
compresses. 


CHAPTER    XXXV. 

FRACTURES  OF  THE  PHALANGES  OF  THE  TOES. 

If  fractures  of  the  other  bones  of  the  foot  are  generally  of  such  a 
character  as  to  require  immediate  amputation,  these  fractures  demand 
this  extreme  resort  still  more  often.  Our  experience,  therefore,  in  the 
treatment  of  fractures  of  the  phalanges  of  the  toes  is  extremely  limited. 

Lonsdale  observes  that  it  is  not  uncommon  to  find  great  irritation 
arise  after  fracture  of  the  great  toe  ;  an  inflammation  extending  along 
the  absorbents  on  the  inside  of  the  leg  to  the  groin,  causing  abscesses 
to  form  in  different  parts  of  the  limb,  and  producing  sometimes  great 
constitutional  disturbance.  An  illustrative  case  has  come  under  my 
own  observation  at  the  Buffalo  Hospital  of  the  Sisters  of  Charity. 
The  patient,  Morgan  McMann,  sdt.  18,  was  admitted  Dec.  23,  1853, 
having  several  days  before  received  an  injury  upon  the  great  toe 
which  contused  the  flesh  severely  and  broke  the  first  phalanx.  He 
was  then  suffering  from  severe  pain  in  the  foot  and  leg,  and  the 
absorbents  were  inflamed  quite  to  the  groin.  Poultices  being  applied 
to  the  foot  and  cool  lotions  to  the  limb,  the  inflammation  soon  sub- 
sided, but  not  until  a  portion  of  the  toe  had  sloughed  away.  Even- 
tually also  it  became  necessary  to  remove  some  portion  of  the  phalanx, 
which  had  died ;  after  which  the  wounds  healed  kindly. 

When  any  of  the  smaller  toes  are  broken,  it  will  be  found  easier  to 
support  the  fragments  by  a  broad  and  long  splint  which  shall  cover 
the  whole  sole  of  the  foot  and  all  the  toes  at  the  same  time,  than  to 
attempt  to  apply  a  splint  to  the  broken  toe  alone.     If,  however,  we 


GUNSHOT    FRACTURES.  483 

prefer  this  latter  mode,  a  thin  piece  of  gutta  percha  will  be  found 
altogether  the  most  convenient  material  for  the  purpose. 

If  the  great  toe  is  broken,  its  great  breadth  may  prevent  any  dis- 
placement, and  a  well-moulded  gutta-percha  splint  will  generally 
secure  a  perfect  and  rapid  union. 


CHAPTER    XXXVI. 

GUNSHOT  FRACTURES. 

Gunshot  fractures  have  already  been  considered,  more  or  less  in 
detail,  in  the  several  portions  of  this  work,  wherever  it  seemed  to  be 
necessary  to  call  especial  attention  to  them.  This  chapter  will  be 
devoted,  therefore,  to  a  brief  resume  of  my  own  observations  and  con- 
clusions in  this  department ;  to  which  will  be  added  a  few  general 
statistical  statements,  drawn  chiefly  from  the  published  records  of  the 
late  war. 

Causes. — Gunshot  fractures  are  caused  by  a  great  variety  of  missiles, 
such  as  musket  and  rifle  balls,  solid  shot  and  shell,  grape,  canister, 
shrapnel,  chain  and  bar  shot,  fragments  of  iron,  stone,  splinters  of 
wood,  &c.  &c.  The  only  qualities  which  these  missiles  possess  in 
common  is,  that  they  are  all  projected  by  the  elastic  power  of  gun- 
powder, and  generally  strike  the  body  with  great  force ;  and  that  they 
cause  fractures  by  direct  violence — seldom  if  ever  by  counter-stroke. 

Round,  smooth  balls  frequently  impinge  upon  bones  without  caus- 
ing a  fracture,  for  the  reason  that  they  are  easily  deflected  ;  and  this 
happens  especially  when  they  are  not  moving  with  great  velocity. 

Conical  rifle-balls  seldom  fail  to  fracture  the  bones  which  lie  in  their 
direct  course ;  never,  perhaps,  when,  at  the  moment  of  contact,  the  ball 
is  moving  with  its  average  velocity.  The  peculiar  destructiveness  of 
this  missile  is  due  to  its  weight,  momentum,  and  form. 

Canister,  grape,  shrapnel,  solid  shot,  shells,  chain  and  bar  shot  are 
still  more  destructive  ;  generally  tearing  the  limbs  from  the  body  in 
such  a  manner  as  to  render  readjustment  and  restoration  impossible. 

Pathology. — These  fractures  may  be  simple,  compound,  comminuted, 
or  complicated  ;  and  in  addition  to  these  common  varieties  of  fractures 
there  is  occasionally  presented  an  example  of  simple  "  perforation,"  or 
mere  penetration  of  the  bone  without  fissure  or  other  fracture ;  and 
still  more  frequently  are  seen  examples  of  perforation  with  fissures. 

Probably  ninety-nine  per  cent,  of  all  gunshot  fractures  are  both 
compound  and  comminuted ;  the  comminution  being,  in  general,  ex- 
cessive. 

As  in  gunshot  wounds  of  the  soft  parts  it  has  been  generally- 
observed  that  the  point  of  entrance  is  more  round,  more  smooth,  and 
somewhat  smaller  than  the  point  of  exit,  and  that  the  tissues  are  a 
little  depressed  at  the  entrance,  while  they  are  slightly  protruded  at 


484  GUNSHOT    FRACTUEE3. 

the  exit,  so  also  in  gunshot  fractures  it  will  often  be  found  that  the 
side  of  the  bone  on  which  the  ball  has  entered,  or  upon  which  it  first 
impinged,  is  less  comminuted  than  the  opposite  side  ;  and,  if  it  is  a 
"perforation,"  that  the  opening  is  smaller  upon  the  one  side  than  upon 
the  other;  that  the  edges  are  slightly  depressed  upon  the  one  side, 
and  elevated  or  protruded  upon  the  other;  and,  finally,  that  numerous 
small,  as  well  as  some  large,  fragments  of  bone  have  been  carried  into 
that  portion  of  the  track  of  the  wound  which  lies  between  the  bone 
and  the  point  of  exit  of  the  missile. 

When  a  ball  fractures  the  shaft  of  a  long  bone,  although  the  blow 
may  have  been  received  three,  four,  or  even  six  inches  from  an  arti- 
culation, the  comminution  or  a  single  longitudinal  fissure  may  some- 
times be  found  extending  into  the  joint.  These  fissures  or  splittings 
of  the  shaft  often  extend  also  a  long  distance  up  or  down,  without 
terminating  in  the  joint. 

Perforations  without  fissure  occur  most  often  in  the  broad  bones 
of  the  pelvis,  in  the  scapula,  or  in  the  spongy  extremities  of  the  long 
bones.  In  the  latter,  however,  it  is  exceedingly  rare  to  find  perfora- 
tion without  fissure. 

Perforations  with  fissure  are  pretty  common  in  the  head  of  the 
humerus  and  in  the  head  of  the  tibia;  they  occur  also,  but  less  often, 
in  the  lower  ends  of  the  femur  and  tibia,  in  the  trochanteric  portion 
of  the  femur,  and  in  the  head  of  the  femur.  We  wish  to  be  under- 
stood to  say  that  fissures  occur  less  often  at  the  points  last  mentioned, 
simply  because  perforations  are  there  less  common.  It  must  be 
known  that  if  perforations  do  occur  at  these  points,  a  splitting  or 
fissure  communicating  with  the  joints  is  almost  inevitable.  A  mis- 
understanding here  would  lead  to  a  very  fatal  error  in  many  cases. 

Prognosis. — In  general  it  may  be  stated  that  gunshot  fractures  of 
the  upper  extremities  do  not  demand  amputation,  and  that  similar 
injuries  in  the  lower  extremities  do  demand  amputation. 

This  statement  is  very  broad,  and  cannot  be  understood  except  by 
a  consideration  of  these  accidents  somewhat  in  detail.     Thus: — 

Gunshot  fractures  of  the  clavicle,  scapula,  of  the  shaft  of  the  hu- 
merus, of  the  shafts  of  the  radius  and  ulna,  and  of  the  carpal,  meta- 
carpal, and  phalangeal  bones,  notwithstanding  these  bones  have  suf- 
fered extensive  comminution,  do  not  usually  demand  amputation  ;  they 
will  in  most  cases  eventually  unite,  and  give  to  the  patients  tolerably 
useful  limbs.  If,  however,  at  the  same  time  that  the  shaft  of  the 
humerus,  or  of  the  radius  and  ulna,  is  thus  broken,  the  large  nervous 
trunks  are  torn  asunder,  so  that  the  extremity  is  cold  and  insensible, 
the  limb  cannot  probably  be  saved,  nor,  if  it  could  be,  would  it  be  of 
any  value.  Destruction  of  the  main  artery  supplying  the  limb  dimi- 
nishes the  chance  of  its  being  saved,  but  does  not,  in  the  case  of  the 
upper  extremities,  necessarily  demand  amputation. 

Penetration  of  the  shoulder-joint  by  a  musket  or  rifle  ball,  pro- 
ducing a  fracture  of  the  head  of  the  humerus  or  of  the  glenoid  cavity 
of  the  scapula,  demands  amputation  when  either  the  axillary  artery 
or  axillary  nerves  are  injured;  but  resection  can  generally  be  prac- 
tised with  a  reasonable  chance  of  success  when  the  arteries  and  nerves 


GUNSHOT    FEACTURES.  485 

are  untouched.  Eesection  is  also  made  successfully  at  the  shoulder- 
joint  in  some  cases  where  larger  missiles  have  traversed  the  joint, 
such  as  canister,  fragments  of  shell,  &c. 

Penetration  of  the  elbow-joint  by  a  large  shot,  or  by  a  Minnie  rifle 
ball,  the  missile  fairly  entering  or  traversing  the  joint,  demands  am- 
putation when  the  main  arterial  and  nervous  supplies  are  cut  off,  and 
resection,  generally,  when  both  remain  uninjured.  Eesection  may  be 
attempted  at  the  elbow-joint,  also,  in  some  cases  where,  the  nervous 
supply  remaining  good,  only  one  of  the  principal  arterial  trunks  is 
cut  off. 

Frequently  a  ball  strikes  the  outer  or  inner  condyle  of  the  humerus, 
making  but  a  small  opening  into  the  joint,  and  producing  only  slight 
comminution,  and  in  such  cases  we  often  save  the  limb  with  more  or 
less  anchylosis,  and  without  resection. 

The  remarks  which  we  have  made  in  reference  to  gunshot  fractures 
of  the  elbow-joint  apply,  almost  without  qualification,  to  the  same 
accidents  at  the  wrist-joint. 

For  gunshot  wounds  with  fracture  of  the  carpal,  metacarpal,  and 
phalangeal  bones  we  seldom  practise  either  resection  or  amputation, 
unless  the  soft  parts  are  almost  completely  torn  away. 

The  prognosis  which,  as  we  have  now  seen,  is  so  favorable  in  the 
upper  extremities,  will  be  found  very  different  in  the  lower  extremi- 
ties; indeed,  it  is  almost  reversed.     Thus: — 

Gunshot  fractures  of  the  shaft  of  the  thigh,  of  the  shafts  of  the  tibia 
and  fibula,  and  of  the  tarsal  bones,  generally  demand  amputation;  or, 
to  be  more  precise,  gunshot  fractures  of  the  head  and  neck  of  the 
femur  almost  always  terminate  fatally  under  amputation  or  excision, 
and  equally  under  treatment  as  fractures,  that  is,  where  an  attempt  is 
made  to  save  the  limb  without  interference  with  the  knife.  The  same 
accidents  in  the  upper  third  of  the  shaft  of  the  femur  are  generally 
fatal;  but  if  the  main  artery  and  the  principal  nerves  are  uninjured, 
the  life  is,  in  general,  less  hazarded  by  an  attempt  to  save  the  limb 
than  by  amputation.  In  the  middle  third,  under  the  same  circum- 
stances, the  chances  may  be  considered  equal,  as  between  amputation 
and  the  attempt  to  save  the  limb  by  apparatus ;  in  the  lower  third 
the  chances  are  in  favor  of  amputation. 

The  above  statements  in  relation  to  fractures  of  the  femur  are  based 
mainly  upon  my  own  experience,  and  have  been  carefully  considered. 

I  have  seen  no  resections  of  the  knee-joint,  and  but  few  of  the  shaft 
of  the  femur,  after  gunshot  fractures,  which  have  not  terminated  fatally ; 
and  I  am  convinced  that  they  should  never  be  attempted  in  fractures 
of  the  thigh,  unless  it  be  that  case  which  presents  so  little  hope  in  any 
direction,  viz.,  gunshot  fracture  of  the  head  or  neck  of  the  femur. 

Gunshot  fractures  of  the  shafts  of  both  tibia  and  fibula  demand 
amputation  where  the  comminution  is  extensive,  or  the  pulsation  of 
the  posterior  tibial  artery  is  lost,  or  the  foot  is  cold  and  insensible. 
We  do  not  mean  to  say  that  some  limbs  thus  situated  have  not  been 
saved,  but  only  that  the  attempt  to  save  such  limbs  greatly  endangers 
the  life  of  the  patient,  while  amputation  at  or  below  the  knee  is  rela- 
tively safe. 


486  GUNSHOT    FEACTURES. 

Amputation  is  the  only  safe  expedient  in  deep  penetrating  wounds 
of  the  tarsal  bones  produced  by  missiles  of  the  size  of  musket-balls 
or  larger.  The  only  exceptions,  which  can  safely  be  made,  are  in 
cases  where  balls  have  opened  partially  and  superficially  these  articu- 
lations. 

Eesections  at  the  ankle-joint  are  much  more  hazardous  than  ampu- 
tations, and  scarcely  to  be  preferred,  in  army  practice,  to  attempts  to 
save  the  foot  without  surgical  interference. 

Treatment. — While  considering  the  prognosis  in  these  accidents,  I 
have  necessarily  spoken  of  the  treatment  in  certain  cases;  especially 
with  a  view  to  the  propriety  of  amputation  or  resection.  It  remains 
only  to  speak  briefly  of  the  treatment  of  those  cases  in  which  we  may 
attempt  to  save  the  limb  without  resection,  properly  so  called ;  for  we 
must  not  forget  that  pretty  often  we  find  it  necessary  to  remove  small, 
loose  fragments  of  bone  by  the  finger,  or  by  the  aid  of  the  knife,  or  to 
resect  sharp  points  with  the  saw  or  the  bone-cutters,  when  we  do  not 
practise  "  resection,"  in  the  sense  in  which  this  term  is  usually  em- 
ployed by  surgical  writers. 

I  shall  take  the  liberty,  in  this  connection,  of  reproducing  what  I 
have  written  elsewhere  in  relation  to  gunshot  fractures,  since  it  com- 
prises nearly  all  that  seems  necessary  to  be  added  upon  this  subject.^ 

"  If  an  attempt  is  made  to  save  a  limb  badly  lacerated  and  broken, 
certain  conditions  in  the  treatment  are  necessary  to  success. 

"All  projecting  pieces  of  bone  which  cannot  be  easily  replaced  and 
are  not  firmly  attached  to  the  soft  parts,  must  be  at  once  cut  or  sawn 
away. 

"All  foreign  substances,  such  as  fragments  of  balls  or  other  missiles, 
pieces  of  cloth,  wadding,  dirt,  &c.,  must  be  removed. 

"Any  portions  of  integument,  fascia,  or  muscles,  which  are  entangled 
in  the  wound,  and  prevent  a  thorough  exploration,  or  may  obstruct 
the  free  escape  of  blood  or  of  matter,  must  be  freely  divided. 

"Counter-openings  must  be  made  at  once,  or  at  an  early  period 
after  the  formation  of  matter,  to  insure  its  easy  escape. 

"  The  limb  must  be  placed  in  an  easy  position,  and  not  confined  by 
tight  bandages  oy  forcibly  extended  by  apparatus. 

"  The  inflammation  must  be  controlled  by  constitutional  and  local 
means,  and  especially  by  the  use  of  water  lotions  whenever  their  em- 
ployment is  practicable." 

If  joints  are  implicated  seriously,  and  an  attempt  is  still  made  to 
save  the  limb,  the  joint  surfaces  must  be  laid  freely  open,  so  as  to 
prevent  all  possibility  of  the  confinement  of  blood,  serum,  or  pus;  and 
the  joint  must  be  placed  perfectly  at  rest,  without  adhesive  strips, 
bandages,  or  any  apparatus  which  shall  compress  the  limb  or  em- 
barrass its  circulation. 

I  do  not  know  that  it  is  necessary  to  speak  more  particularly  of  the 
treatment  of  gunshot  fractures,  unless  it  be  to  say  that  I  still  give  the 
preference,  in  fractures  of  the  femur,  to  the  straight  position.     In 

'  Treatise  on  Military  Surgery,  by  Frank  Hastings  Hamilton.  1  vol.  8vo.  Pub- 
lished by  Bailliere  Brothers.  New  York,  1861;  also  enlarged  ed.  of  same  work  in 
1865. 


GUNSHOT    FRACTURES. 


487 


most  cases  I  have  preferred  my  own  apparatus,  already  described 
when  speaking  of  fractures  of  the  thigh  in  general,  with  moderate  ex- 
tension; and  by  moderate  extension  is  to  be  understood  such  as  may 
be  effected  with  from  five  to  ten  pounds. 

A  movable  canvas,  such  as  is  shown  in  the  accompanying  wood- 
cut, with  a  hole  in  the  centre,  and  reinforced  by  an  additional  piece 

Fisr.  223. 


Author's  movable  canvas. 


of  canvas  where  the  weight  of  the  hips  rests,  will  enable  the  surgeon 
to  move  his  patient  and  clean  the  bed  when  necessary.  The  standard 
which  supports  the  pulley  can  be  received  in  a  slot  in  the  frame. 


Fiff.  224. 


Movable  canvas,  with  extension,  on  "horses. 


^  An  apparatus  similar  to  this  was  used,  during  our  late  war,  in  the 
Lincoln  General  Hospital  at  Washington. 

I  have  also  used,  with  the  movable  canvas,  and  upon  an  ordinary  bed, 
Eodgen's  apparatus,  or  "  cradle"  as  he  terms  it,  and  have  found  it  ex- 
ceedingly useful,  and  much  preferable  to  any  form  of  double-inclined 


488  GUNSHOT    FRACTURES. 

plane,  whether  suspended  or  not.  The  cradle  is  simply  a  skeleton 
box,  of  the  length  of  the  thigh  and  leg,  made  of  light  strips  of  wood. 
Across  the  two  upper  bars  are  laid,  transversely,  cloth  bands,  upon 
which  the  limb  is  laid  at  full  length.^ 

As  supplementary  to  this  chapter,  it  seems  proper  to  add  a  brief 
resume  of  the  statistics  of  the  war  of  the  rebellion  just  closed,  drawn 
from  the  reports  of  the  Surgeon-General,  made  in  1865  and  in  1867.^ 

Of  4167  gunshot  wounds  of  the  face,  1579  were  accompanied  with 
fractures  of  the  facial  bones.  Of  these  latter,  107  died,  and  891  re- 
covered. The  remainder  are  undetermined.  Secondary  hemorrhage 
is  said  to  have  been  the  most  frequent  cause  of  death. 

Of  187  examples  of  gunshot  injuries  of  the  spine  (not  including 
those  in  which  the  chest  or  abdomen  was  penetrated),  180  died.  Six 
of  those  reported  as  having  recovered  were  examples  of  fracture  of 
the  transverse  or  spinous  processes.  The  seventh  is  that  of  a  soldier 
wounded  at  Chicamauga,  September  20th,  1863,  by  a  musket-ball, 
which  fractured  the  spinous  process  of  the  fourth  lumbar  vertebra,  and 
penetrated  the  vertebral  canal.  The  ball  and  fragments  of  bone  were 
extracted,  and  one  year  after  he  was  reported  as  "  likely  to  recover." 

Of  359  gunshot  wounds  of  the  pelvis  (not  including  those  in  whicb 
the  abdominal  cavity  was  penetrated),  77  died,  and  97  recovered.  In 
the  remainder  the  result  is  not  ascertained.  In  256  cases  the  ilium 
alone  was  injured;  in  19,  the  ischium  alone;  in  12,  the  pubes;  in  32, 
the  sacrum ;  and  in  40  cases  the  lesions  extended  to  two  or  more  por- 
tions of  the  innomiuata.     Pyaemia  was  a  frequent  cause  of  death. 

Of  1689  gunshot  fractures  of  the  humerus,  436  died,  and  1253  re- 
covered. Nine  hundred  and  ninety-six  of  these  1689  cases  were 
treated  by  amputation  or  resection,  with  a  mortality  of  21  per  cent. 
In  693  cases  the  conservative  treatment  was  adopted,  with  a  mortality 
of  30  per  cent. 

Of  68  cases  in  which  attempts  were  made  to  save  the  limb  after 
gunshot  injury  of  the  hip-joint,  without  resection,  all  died.  (I  have 
seen  two  cases  of  successful  treatment  of  these  accidents  by  the  con- 
servative plan,  and  others  have  been  reported.) 

Fifty-three  amputations  at  the  hip-joint,  made  by  surgeons  in  the 
federal  and  confederate  armies,  including  also  reamputations,  gave 
seven  successful  results.     The  fate  of  two  is  uncertain. 

Sixty-three  excisions  at  the  same  joint,  made  by  federal  and  con- 
federate surgeons,  furnished  five  successful  cases. 

Three  hundred  and  thirty  cases  of  gunshot  fracture  of  the  upper 
third  of  the  shaft  of  the  femur,  in  which  neither  amputation  nor  resec- 
tion was  practised,  gave  a  mortality  of  71.81.  Thirty-two  cases  in 
which  amputation  was  made  gave  a  mortality  of  75  per  cent.  Twenty- 
two  in  which  resection  was  made,  gave  a  mortality  of  81.18.  (We 
have  rejected  three  cases  given  in  the  report  as  cured.  Two  of  these 
were  resections  of  the  head,  and  one  was  merely  a  "rounding  off  of 
sharp  edges.") 

'  Hodgen,  Treatise  on  Military  Surg.,  by  the  author,  p.  408. 
2  Circular  No.  6,  Surgeon-General's  Office  ;  also  Circular  No.  7. 


GUNSHOT    FRACTURES.  4b9  ' 

Two  hundred  and  thirty-two  cases  of  gunshot  fractures  of  the  mid- 
dle third,  treated  without  amputation  or  resection,  gave  a  mortality  of 
55.46.  Ninety-three  treated  by  amputation  gave  a  mortality  of  54.88. 
Fifteen  treated  by  resection  gave  a  mortality  of  86.66. 

One  hundred  and  seventy-three  gunshot  fractures  of  the  lower  third, 
treated  without  amputation  or  resection,  gave  a  mortality  of  57.79. 
Two  hundred  and  forty-three  amputated — mortality  46.09.  Two  re- 
sected— both  died. 

Of  308  gunshot  wounds  of  the  knee-joint,  with  or  without  fracture, 
treated  without  amputation  or  resection,  258  died — mortality  83.76. 
Of  the  50  which  recovered  there  were,  however,  only  six  or  eight  in 
which  the  testimony  is  unequivocal  that  the  joint  was  opened.  Of  452 
amputated,  331  died — mortality  73.23.  Of  10  resected,  9  died— mor- 
tality 90  per  cent. 

Of  696  gunshot  fractures  of  the  leg,  169,  or  24  per  cent.,  were  fatal. 

No  analyses  have  been  made  of  fractures  of  the  smaller  bones. 

It  is  much  to  be  regretted  that  in  these  comparative  analyses  of 
the  treatment  of  gunshot  fractures,  except  in  the  case  of  the  hip-joint, 
by  the  three  methods,  it  is  not  stated  whether  the  amputations  or 
resections  were  primary  or  secondary.  In  all  secondary  amputations 
and  resections,  which,  for  aught  that  appears,  may  have  constituted  a 
majority  of  the  whole  number,  the  conservative  treatment  had  been 
tried  and  had  failed,  and  the  deaths  which  followed  ought  in  justice  to 
be  charged  to  conservatism,  and  not  to  the  operation.  As  the  reports 
now  stand,  they  are  of  little  or  of  no  importance  in  determining  the 
relative  value  of  conservative  and  operative  treatment. 

From  the  reports  of  the  Confederate  army,  as  published  in  the  Oon- 
federate  States  Medical  Journal,  we  learn  that  of  221  cases  of  gunshot 
fractures  of  the  thigh  treated  without  amputation  or  resection,  105 
died,  and  116  recovered.  The  shortest  period  of  recovery  was  41  days ; 
the  longest,  255  days ;  the  average,  104  days.  The  shortest  period  of 
fatal  termination  was  one  day;  the  longest,  185  days;  average,  52 
days.  Greatest  shortening,  five  inches ;  least,  half  an  inch ;  average, 
one  inch  and  nine-tenths.^ 

Of  507  amputations  for  gunshot  fractures  of  the  thigh,  250  recov- 
ered.^ 

'  Riclimond  Med.  Journ.,  Feb.  1866,  from  Confederate  States  Med.  Journal. 
2  Ibid.,  January,  1866,  p.  52. 


32 


PART   II. 


DISLOCATIONS 


DISLOCATION'S. 


CHAPTER   I. 

GENERAL  CONSIDERATIONS. 

§  1.  General  Division  and  Nomenclature. 

A  DISLOCATION  is  the  displacement  of  one  bone  from  another  at  its 
place  of  natural  articulation. 

Dislocations  may  be  divided  into  accidental  or  traumatic,  sponta- 
neous or  pathologic,  and  congenital. 

Our  remarks  upon  the  etiology,  pathology,  symptomatology,  prog- 
nosis, and  treatment  of  these  injuries  must  be  considered  as  applicable 
only  to  accidental  or  traumatic  dislocations,  unless  the  fact  is  in  any 
case  otherwise  stated. 

Accidental  dislocations  are  those  in  which  the  bones  have  suffered 
displacement  in  consequence  of  the  application  of  a  sudden  force;  and 
surgeons  have  divided  these  accidents  into  Complete  and  Partial, 
Simple,  Compound  and  Complicated,  Recent  and  Ancient,  Primitive 
and  Consecutive. 

A  complete  dislocation  is  one  in  which  no  portions  of  the  articular 
surfaces  remain  in  contact. 

A  partial  dislocation  is  one  in  which  the  articular  surfaces  are  not 
completely  removed  from  each  other. 

A  simple  dislocation  is  that  form  of  the  accident  in  which  the  bone 
has  only  slid  from  its  articulation,  and  is  accompanied  with  the  least 
or  only  an  average  amount  of  injury  to  the  soft  parts  or  to  the  bones 
adjacent  to  the  joint. 

A  compound  dislocation  implies  that  the  articulating  surface  of  the 
bone  has  been  thrust  through  the  flesh  and  skin;  or  that  in  some  other 
way  a  wound  has  been  made  which  communicates  with  the  joint. 

Complicated  dislocation,  is  a  term  employed  by  some  writers  to 
designate  a  condition  wholly  differing  from  a  compound  dislocation, 
or,  in  some  cases,  a  condition  of  extra  complication.  Thus,  a  simple 
dislocation  may  be  complicated  with  a  fracture,  or  with  the  laceration 
of  an  important  bloodvessel,  &c.;  and  a  compound  dislocation  may  be 
complicated  in  the  same  way,  and  with  the  addition,  perhaps,  of  exten- 
sive laceration  and  destruction  of  integument,  muscles,  nerves,  &c. 


494  GENERAL    CONSIDERATIONS. 

A  recent  luxation,  has  taken  place  within  a  period  of  a  few  days,  or, 
at  most,  of  a  few  weeks;  and  an  ancient  luxation  has  existed  during 
a  longer  period.  The  exact  point  of  time  at  which  a  dislocation  shall 
be  called  recent  or  ancient  is  not  fully  determined  by  surgeons,  and 
the  application  of  these  terms  is  therefore  always  somewhat  arbitrary. 

A  primitive  luxation,  is  a  luxation  in  which  the  bone  remains  nearly 
or  precisely  in  the  position  into  which  it  was  at  first  thrown;  while  a 
secondary  or  consecutive  luxation  is  one  in  which  the  bone  has  sub- 
sequently, in  consequence  of  the  action  of  the  muscles,  or  from  un- 
successful efforts  at  reduction,  or  from  some  other  cause,  changed  its 
position  suiSciently  to  entitle  the  accident  to  a  new  designation.  Thus 
a  primitive  dislocation  upon  the  ischiatic  notch  may  become  a  second- 
ary dislocation  upon  the  dorsum  ilii,  or  the  reverse. 


§  2.  General  Predisposing  Causes. 

Age. — According  to  Malgaigne,  whose  conclusions  are  based  upon 
an  analysis  of  six  hundred  and  forty-three  cases,  dislocations  are  very 
rare  in  infancy,  only  one  having  occurred  under  five  years;  but  the 
frequency  increases  gradually  up  to  the  fifteenth  year,  from  this  period 
more  rapidly  up  to  the  sixty-fifth  year,  and  from  this  time  onward 
again  dislocations  become  more  rare.  He  has  mentioned  none  after 
the  ninetieth  year ;  and  the  period  of  greatest  frequency  is  between 
the  thirtieth  and  sixty-fifth  year.  To  this  middle  period  belong  four 
hundred  and  seven  of  the  whole  number. 

The  inference  from  this  analysis  may  be  thus  briefly  stated:  age,  as 
a  predisposing  cause,  is  most  active  in  middle  life,  less  active  in  ad- 
vanced life,  and  least  active  of  all  in  early  life. 

It  is  proper,  however,  to  observe  that  while  such  statistics  may  be 
relied  upon  as  indicating  the  relative  frequency  of  these  accidents  at 
different  periods  of  life,  they  cannot  be  regarded  as  determining  abso- 
lutely the  value  of  age  alone  as  a  predisposing  cause,  since  the  direct 
or  exciting  causes  may  be  more  active  at  one  period  than  another,  and 
in  some  measure  these  latter  causes  may  be,  and  doubtless  are,  respon- 
sible for  such  results. 

Constitution,  and  Oondition  of  the  Muscles  and  Ligaments. — It  may  be 
stated  as  a  general  fact  that  persons  of  feeble  constitutions,  and  whose 
muscular  systems  are  much  weakened,  suffer  dislocation  from  slighter 
causes  than  those  who  are  in  health,  and  whose  muscular  systems  are 
firm  and  vigorous ;  and  that  a  relaxation  of  the  ligaments  which  sur- 
round a  joint,  however  this  may  have  been  occasioned,  predisposes  to 
dislocation.  Thus,  a  paralyzed  and  atrophied  limb  is  predisposed  to 
luxation ;  a  joint  in  which  the  capsule  has  become  stretched  by  effu- 
sions, or  by  violent  extension,  or  weakened  by  laceration  from  a 
previous  dislocation,  or  by  ulceration,  or  if  in  any  other  way  the 
articulation  is  deprived  of  these  natural  protections,  we  need  scarcely 
say  that  it  is  thereby  rendered  more  liable  to  luxation. 

Ball  and  socket  joints,  other  things  being  equal,  are  more  liable  to 
displacement  than  ginglyraoid;  but  then  much  more  depends  upon 


GENERAL    SYMPTOMS.  495 

the  relative  exposure  of  the  joint  than  upon  its  anatomical  structure, 
so  that  the  elbow  is  much  more  frequently  dislocated  than  the  hip ; 
the  shoulder-joint,  however,  being,  from  its  position  and  extent  of 
motion,  peculiarly  exposed,  and  being  also  a  ball  and  socket  joint,  is, 
of  all  others,  most  liable  to  dislocation. 

§  3.  Direct  or  Exciting  Causes. 

These  may  be  classed  under  two  general  heads,  namely,  external 
violence  and  muscular  action. 

External  violence  operates  either  directly  or  indirectly.  When  a 
person  falls  upon  the  knee  and  dislocates  the  head  of  the  femur,  the 
force  is  said  to  have  acted  indirectly,  and  this  is  by  far  the  most 
frequent  mode  of  dislocation;  but  when  the  blow  is  received  upon  the 
upper  end  of  the  humerus,  and  its  head  is  sent  into  the  axilla,  it  is 
said  to  have  been  dislocated  by  direct  violence. 

Muscular  action  produces  a  dislocation  slowly,  as  in  some  cases  of 
chronic  rheumatism,  and  then  it  is  called  a  spontaneous  or  pathologic 
dislocation ;  or  suddenly,  as  in  the  violent  spasmodic  contractions 
which  accompany  convulsions;  or  sometimes  by  the  mere  voluntary 
effort  of  the  muscles;  and  both  of  these  latter  are  true  accidental 
luxations. 

It  is  very  probable  that  external  force  can  seldom  be  regarded  as 
the  sole  cause  of  a  dislocation,  but  that,  in  a  large  majority  of  cases, 
muscular  action  consenting  with  the  shock,  performs  an  important 
r6le  in  the  history  of  the  accident.  The  limb  being  driven  obliquely 
across  its  socket  by  the  external  violence,  is  seized  by  the  stretched 
and  excited  muscles  with  such  vigor  as  to  contribute  not  a  little  to 
the  unfortunate  result.  Thus  it  will  be  found  that  the  same  force 
which  is  adequate  to  the  production  of  a  dislocation  in  the  living  and 
healthy  subject  is  wholly  insufficient  to  accomplish  the  same  in  the 
dead;  and  a  man  who  is  fully  intoxicated  seldom  suffers  a  dislocation. 

§  4.  General  Symptoms. 

As  fractures  are  characterized  by  preternatural  mobility  and  crepi- 
tus, to  which  may  be  generally  added  the  circumstance  that  when 
reduced  the  fragments  will  not  remain  in  place  without  external 
support,  so,  on  the  other  hand,  dislocations  are  characterized  by  pre- 
ternatural rigidity,  an  absence  of  crepitus,  and  by  the  fact  that  when 
reduced  the  bone  does  not  generally  require  support  to  maintain  it 
in  position. 

_  These  three  are  the  usual,  and  they  may  be  termed  the  common, 
signs  of  distinction  between  fractures  and  dislocations,  but  no  one  of 
them  can  be  alone  depended  upon  as  positively  diagnostic.  Generally, 
when  a  bone  has  been  dislocated,  we  shall  find  the  limb  in  a  certain 
position,  which  is  uniform  for  all  dislocations  of  the  same  character, 
and  almost  immovably  fixed;  but  when  the  ligaments  and  muscles 
about  the  joint  have  been  extensively  torn,  or  the  whole  body  is  still 
suffering  under  the  shock,  or  in  any  other  circumstances  where  the 


496  GENERAL    CONSIDERATIONS. 

power  of  the  muscles  is  weakened,  this  rigidity  may  give  place  to 
extreme  mobility. 

True  crepitus  does  not  exist  without  fracture,  but  is  not  always 
present  in  fractures,  and  there  is  often  a  sensation  produced  in  the 
rubbing  and  chafing  of  dislocated  bones  which  very  much  resembles 
certain  kinds  of  crepitus,  and  by  the  inexperienced  has  been  often 
mistaken  for  it.  I  allude  to  the  subdued  rasping  sound  or  sensation 
which  is  found  generally  on  the  second  or  third  day,  and  sometimes 
earlier,  and  which  is  the  result  of  fibrinous  effusions,  or,  perhaps,  in 
some  instances,  of  the  mere  rubbing  of  firmly  compressed  ligamentous 
and  cartilaginous  surfaces  upon  each  other.  The  crepitus  of  a  recent 
fracture  can  be  scarcely  confounded  with  this  obscure  sensation,  unless 
it  is  in  some  cases  of  incomplete  fracture,  or  of  a  fracture  situated 
remote  from  the  surface,  as  in  the  case  of  the  hip;  but  a  fracture 
which  is  a  few  days  old,  whose  surface  has  become  softened  by  in- 
flammation and  more  or  less  covered  with  lymph,  and,  when  the 
rigidity  is  great,  may  sometimes  deceive  the  most  experienced  sur- 
geon, so  exactly  will  it  be  found  to  imitate  the  sensations  produced 
by  the  chafing  of  an  inflamed  joint,  or  of  closely  approximated  fibrous 
surfaces. 

I  have  said  that  a  true  crepitus  does  not  exist  without  a  fracture ; 
but  then  a  very  minute  fracture,  such  as  the  detachment  of  a  scale  of 
bone  by  the  tearing  away  of  a  tendon  or  of  a  ligament,  may  produce 
crepitus;  or  even  the  separation  of  a  piece  of  cartilage  may  sufficiently 
expose  the  bone  to  determine  the  presence  of  this  phenomenon.  These 
are,  however,  no  longer  examples  of  simple  dislocation. 

Nor  are  the  two  inverse  propositions,  in  relation  to  the  retention  of 
the  bones  in  place,  invariable  in  their  application.  A  broken  bone, 
well  reduced,  does  not  always  manifest  a  tendency  to  displacement, 
nor  does  a  dislocated  limb,  when  restored  to  its  socket,  in  all  cases 
maintain  its  position  without  support. 

The  other  general  signs  of  dislocation  are  pain,  swelling,  and  dis- 
coloration. The  pain  is  generally  more  intense  in  dislocations  than 
in  fractures,  the  expanded  end  of  the  bone  resting  often  upon  one  or 
more  large  nerves,  which  usually,  with  the  arteries,  approach  very 
near  the  joints,  this  pressure  being  also  greatly  increased  by  the 
extreme  tension  of  the  muscles.  Not  unfrequently  numbness  and 
temporary  paralj'-sis  of  the  whole  limb  are  the  consequences.  In 
other  cases  the  pain  is  due  solely  to  the  pressure  upon  the  muscles  or 
to  the  tension  of  the  muscles,  or,  perhaps,  to  the  tension  of  the  untorn 
ligaments  and  capsule. 

Generally  the  limb  is  shortened,  but  in  a  few  cases  it  is  found 
slightly  lengthened,  while  the  natural  axis  of  the  bone  with  its  socket 
is  always  changed.  If  examined  early,  and  before  the  supervention 
of  swelling,  the  joint  end  of  the  displaced  bone  may  be  felt  in  its 
unnatural  position,  and  a  corresponding  depression  may  be  discovered 
in  the  situation  of  the  articulation,  especially  if  the  bones  are  super- 
ficial. 


PATHOLOGY.  497 

§  5.  Pathology. 

The  dissection  of  recent  dislocations  produced  bj  external  violence 
shows  the  capsular  ligaments  more  or  less  torn,  and  also  a  rupture  of 
some  of  the  lateral  and  other  short  ligaments,  with  a  complete  rupture 
in  most  cases  of  some  of  the  tendons  which  immediately  surround  the 
joint,  or  of  those  which  are  attached  to  the  capsule:  the  muscles, 
nerves,  arteries,  &c.,  through  which  the  bone  in  its  passage  has  passed, 
or  upon  which  it  is  found  resting,  being  also  contused,  stretched,  or 
torn  assunder. 

This  description,  however,  does  not  apply  to  dislocations  produced 
by  muscular  action  alone,  in  a  majority  of  which  cases  the  capsule  is 
only  stretched,  and  not  torn,  and  no  lesions  of  other  structures  are 
necessarily  present. 

If  the  dislocation  remains  unreduced,  the  margins  of  the  old  socket, 
in  the  case  of  enarthrodial  articulations,  become  gradually  depressed, 
while  the  concavity  of  the  socket  is  filling  in  with  a  fibrous  or  bony 
tissue,  until  at  length  the  whole  of  this  portion  of  the  joint  apparatus 
is  nearly  or  entirely  obliterated.  This  process  is  generally  very  slow, 
and  may  not  be  consummated  until  after  the  lapse  of  many  years. 

At  the  same  time,  but  with  much  greater  rapidity,  the  head  of  the 
bone  in  its  new  position,  and  the  soft  or  hard  parts  upon  which  it  rests, 
are  undergoing  certain  changes  to  adapt  them  to  their  new  relations, 
and  calculated  in  some  measure  to  restore  the  limb  to  its  normal  func- 
tions. If  the  head  of  the  bone  rests  upon  muscle,  the  cellular  and 
fibrous  tissues  which  enter  into  the  composition  of  the  muscle  become 
condensed  and  thickened,  forming  a  shallow  or  elongated  cup,  whose 
margins  are  attached  to  the  neck  or  shaft  of  the  bone,  and  whose  walls 
are  lubricated  with  synovia.  If  it  rests  upon  bone,  by  a  process  of 
interstitial  absorption  a  true  socket  is  formed,  sometimes  deep  and 
sometimes  shallow,  whose  edges,  receiving  additional  ossific  deposi- 
tions, become  lifted  so  as  to  form  a  rim.  At  the  same  time  the  head 
of  the  bone  is  undergoing  corresponding  changes,  to  adapt  itself  to  the 
newly-formed  socket ;  it  is  flattened  or  otherwise  changed  in  form,  and 
in  the  progress  of  this  change  its  natural  secreting  and  cartilaginous 
surfaces  are  gradually  removed,  a  porcelaneous  deposit  taking  its  place. 
The  same  kind  of  hard,  polished,  ivory-like  deposit  is  found  also  in 
those  portions  of  the  new  socket  which  have  been  especially  exposed 
to  pressure  and  friction.  Instead  of  the  eburnation,  an  imperfect 
fibro-serous  surface  or  synovial  capsule  may  be  formed. 

I  have  in  my  cabinet  an  example  of  ancient  luxation  of  the  hip-joint 
in  which  the  head  of  the  femur,  having  rested  upon  the  dorsum  ilii,  has 
formed  a  nearly  flat  but  smooth  surface — a  kind  of  elevated  plateau ; 
in  other  cases  I  have  seen  the  margins  of  the  new  socket  so  elevated 
as  to  rest  against  the  neck  of  the  femur,  and  completely  lock  it  in. 

Consenting  with  these  changes,  and  in  consequence  partly  of  the 
disuse  of  the  limb,  the  muscle,  and  even  the  bones  sometimes,  suffer 
a  gradual  atrophy.  In  some  measure  these  alterations  may  be  due 
also  to  the  pressure  of  the  dislocated  bone  upon  arterial  and  nervous 
trunks,  by  which  their  functions  become  partially  or  completely  anni- 


498  GENEKAL    CONSIDER ATIOKS. 

hilated,  and  their  structure  even  may  be  wholly  obliterated.  In  conse- 
quence also  of  the  inflammation  which  immediately  results,  we  ought 
not  to  omit  to  notice  that  the  trunk  of  a  large  artery  sometimes 
becomes  firmly  adherent  to  the  capsule  or  periosteum  of  a  displaced 
bone,  and  its  reduction  is  attended  with  imminent  danger  of  laceration 
and  of  a  fatal  hemorrhage.  Numerous  instances  of  this  grave  accident, 
especially  in  attempts  to  reduce  old  dislocations  of  the  shoulder-joint, 
are  upon  record. 

§  6.  General  Prognosis. 

We  shall  study  the  prognosis  of  these  accidents  to  better  advantage 
when  we  come  to  speak  of  the  individual  bones  and  their  various 
forms  of  dislocation ;  but  it  is  proper  to  state  in  this  place,  generally, 
that  very  few  joints,  having  been  once  completely  displaced  from  their 
sockets  by  external  violence,  are  ever  so  completely  restored  as  not  to 
leave  some  traces  of  the  accident  for  many  years,  if  not  for  the  whole 
of  the  subsequent  life  of  the  patient,  either  in  the  partial  limitation  of 
their  motions,  or  in  the  diminished  size  and  power  of  the  muscles  of 
the  limbs,  or  in  the  presence  of  an  occasional  arthritic  pain  :  the  degree 
and  permanence  of  these  sequences  depending  upon  the  joint  which  is 
the  subject  of  the  displacement,  the  extent  of  the  original  injury,  the 
length  of  time  it  has  remained  unreduced,  the  means  employed  in  its 
reduction,  the  health  and  condition  of  the  patient,  with  so  many  other 
contingent  circumstances  as  to  preclude  the  idea  of  a  complete  specifi- 
cation. 

If  the  bone  is  not  reduced,  a  permanent  maiming  is  inevitable ;  but 
it  is  surprising  how  much  time  and  the  intelligent  processes  of  nature 
can  eventually  accomplish  toward  a  restoration  of  the  natural  func- 
tions, especially  when  aided  by  a  good  constitution  and  judicious 
treatment.  If  the  symmetry  of  form  and  grace  of  motion  are  never 
replaced,  the  value  of  the  limb,  for  all  the  practical  purposes  of  life, 
is  not  unfrequently  completely  re-established. 

§  Y.  General  Treatment. 

The  first  indication  of  treatment  is  to  reduce  the  bone.  Whatever 
delays  may  be  proper  or  justifiable  in  certain  cases  of  fracture,  such 
delays  are  never  to  be  argued  in  cases  of  dislocation.  The  sooner  the 
reduction  is  accomplished  the  better.  For  this  purpose  we  resort  at 
once  to  such  manipulations  or  mechanical  contrivances  as  the  nature  of 
the  case  demands;  and  if  these  fail,  or  if  at  the  first  they  are  deemed 
insufiicient,  we  invoke  the  aid  of  constitutional  means,  or  such  as  are 
calculated  to  diminish  the  power  and  antagonism  of  the  muscles. 

Many  dislocations  may  be  reduced  promptly  by  manipulation  alone; 
which  mode  is  always  to  be  preferred  when  it  will  prove  sufficient, 
for  the  reasons  that  it  is  generally  the  least  painful  to  the  patient,  and 
the  least  apt  to  inflict  additional  injury  upon  the  muscles  and  liga- 
ments. 

A  person  wholly  unacquainted  with  anatomy  or  surgery  may  occa- 


GENERAL    TREATMENT.  499 

sionally  succeed  in  reducing  a  dislocated  limb ;  indeed  it  frequently 
happens  that  the  patient  himself,  by  mere  accident  in  getting  up  or 
in  lying  down,  accomplishes  the  reduction ;  and  even  in  a  very  large 
majority  of  cases  force  and  perseverance  will  finally  succeed  by  whom- 
soever they  may  be  employed ;  but  the  observing  student  of  surgery 
will  soon  discover  the  difference  between  accident  and  brute  force  on 
the  one  hand,  and  intelligent  manipulation  on  the  other.  The  char- 
latan bone-setter  does  not  often  allow  himself  to  fail,  unless  the  cou- 
rage of  his  patient  gives  out,  or  he  ignorantly  supposes  the  reduction 
to  be  effected  when  it  is  not;  but  his  success,  achieved  through  great 
and  unnecessary  suffering,  is  often  obtained,  also,  at  the  expense  of 
the  limb.  While  the  surgeon,  whose  knowledge  of  anatomy  enables 
him  to  understand  in  what  direction  the  muscles  are  offerino^  resist- 
ance,  and  through  what  ligaments  the  head  of  the  bone  must  be 
guided,  lifts  the  limb  gently  in  his  hands,  and  the  bone  seeks  its 
socket  promptly  and  without  disturbance,  as  if  it  needed  only  the 
opportunity  that  it  might  demonstrate  its  willingness  to  return. 

We  must  understand  not  only  what  muscles  and  ligaments  antag- 
onize the  reduction,  if  we  would  be  most  successful,  bat  also  what 
muscles,  by  being  provoked  to  contraction,  will  themselves  aid  in  the 
reduction.  In  short,  to  become  expert  bone-setters  in  the  department 
of  dislocations,  one  must  possess  a  complete  knowledge  of  the  phy- 
siognomy or  the  external  aspect  of  joints,  acquired  only  by  repeated 
and  careful  examinations,  he  must  be  familiar  with  the  anatomy  and 
functions  of  the  muscles,  he  must  understand  thoroughly  the  ligaments, 
he  must  have  experience,  tact,  and  fertility  of  resource. 

Without  these  qualifications  a  man  will  do  better  never  to  under- 
take to  treat  dislocations,  since  he  is  constantly  liable  to  mistake  frac- 
tures for  dislocations,  and  dislocations  for  fractures  ;  he  will  submit  a 
sprained  wrist  to  violent  extension,  under  the  conviction  that  the 
joint  is  displaced;  he  will  mistake  natural  projections  for  deformities, 
and  fail  to  recognize  the  real  deforrnity  when  it  actually  exists;  he 
will  leave  bones  unreduced,  fully  believing  that  they  are  reduced;  and 
he  will,  all  in  all,  within  a  few  years,  accomplish  vastly  more  evil  than 
he  can  ever  do  good.  Let  a  man  practise  any  other  branch  of  surgery 
if  he  will,  without  experience  or  scientific  knowledge,  but  he  must 
not  attempt  to  reduce  dislocated  bones.  The  most  learned  and  the 
most  skilful  we  shall  find  falling  into  error,  embarrassed  by  the  un- 
certainty of  the  diagnosis,  or  successfully  resisted  by  the  power  of  the 
opposing  agents;  what  then  can  be  expected  of  those  who  are  both 
ignorant  and  inexperienced,  but  failures  and  disasters  ? 

As  a  means  of  disarming  the  muscles,  or  of  placing  them  off"  their 
guard,  we  often  practise  successfully  the  diversion  of  the  mind  of  the 
patient.  At  the  very  moment  that  the  limb  is  moved  or  extension  is 
made,  a  question  is  addressed  to  him,  or  he  may  be  suddenly  surprised 
by  some  unexpected  intelligence. 

Extension  and  counter-extension,  made  with  our  own  hands  or  with 
the  hands  of  assistants,  constitute  the  second  resort  where  manipula- 
tion alone  has  failed.  The  surgeon  seizing  upon  the  limb  firmly  with 
bis  hands,  makes  the  extension,  while  the  assistants  make  the  counter- 
extension  ;  or,  instead  of  grasping  the  limb  directly,  the  operator  may 


500 


GENERAL    CONSIDERATIONS, 


Fig.  235.  use  for  this  purpose  circular  and  longitudinal 

bandages,  or  the  bandage  or  handkerchief  tied 
in  the  form  of  the  clove  hitch.  Extension  is 
thus  applied  in  connection  with  manipula- 
tion, aided,  perhaps,  by  direct  pressure  upon 
the  head  of  the  displaced  bone.  Failing  in 
this,  we  employ  some  one  of  the  various 
mechanical  contrivances  which,  while  they 
are  capable  of  exerting  much  more  power, 
possess  also  the  important  advantage  of 
operating  gradually  and  steadily,  by  which 
mode  the  resistance  of  the  muscles  is  always 
more  speedily  and  more  completely  over- 
come. 

For  this  purpose  surgeons  employ  gene- 
rally in  the  case  of  the  large  limbs,  the  com- 
pound pulleys  or  the  simple  rope  windlass, 
which  latter  is  thus  described  by  Dr.  Gilbert, 
of  Philadelphia:  "Place  the  patient,  and 
adjust  the  extending  and  counter-extending 
bands  as  for  the  pulleys;  then  procure  an 
ordinary  bed-cord  or  a  wash-line,  tie  the  ends 
together  and  again  double  it  upon  itself,  pass  it  through  the  extending 
tapes  or  towels,  doubling  the  whole  once  more,  and  fasten  the  distal 
end,  consisting  of  four  loops  of  rope,  to  a  window-sill,  door-sill,  or 
staple,  so  that  the  cords  are  drawn  moderately  tight ;  finally,  pass  a 
stick  through  the  centre  of  the  double  rope,  then  by  revolving  the 
stick  as  an  axis  or  double  lever,  the  power  is  produced  precisely  as  it 
should  be  in  such  cases,  viz.,  slowly,  steadily,  and  continuously." 


Clove  hitch.     (From  Erichsen.) 


Fii?.  22G. 


Compound  pulleys,  and  ring  to  which  one  end  of  the  pnlley  rope  is  fastened. 

Jarvis's  adjuster,  although  very  complex,  possesses  some  advantages 
over  the  pulleys,  which  may,  perhaps,  entitle  it  to  the  preference  in  a 
few  cases. 

Among  the  constitutional  means,  ether  and  chloroform  occupy  the 
first  rank  ;  indeed  they  are,  at  the  present  day,  almost  the  only  means 


DOUBLE    OR    BILATERAL    DISLOCATION.  501 

of  this  class  to  which  surgeons  resort,  and  their  value  in  this  point 
of  view  can  scarcely  be  overestimated.  Only  when  some  unusual 
circumstance  or  condition  of  the  patient  forbade  the  use  of  an  anees- 
thetic,  would  the  surgeon  return  to  the  ancient  practice  of  bleeding 
ad  deliquium,  of  prostrating  the  system  with  antimony,  or  to  the  use 
of  those  vastly  less  efficient  agents,  opium  and  the  warm  bath. 


CHAPTER  II. 

DISLOCATIONS  OF  THE  LOWER  JAW. 

There  are  two  principal  forms  of  this  dislocation,  namely,  the 
double  or  bilateral  dislocation,  and  the  single  or  unilateral ;  in  both 
of  which  the  direction  of  the  displacement  is  forwards.  To  these 
there  has  been  added  one  example  of  an  outward  displacement 
accompanied  with  a  fracture.^ 

§  1.  Double  or  Bilateral  Dislocations. 

This  form  of  dislocation  of  the  lower  jaw  is  much  the  most  frequent, 
being  met  with  in  about  two  out  of  every  three  cases.  It  appears  also 
to  occur  oftener  in  women  than  in  men,  and  usually  between  the  twen- 
tieth and  thirtieth  year  of  life.  In  infancy  and  extreme  old  age  it  is 
exceedingly  rare ;  yet  Sir  Astley  Cooper  mentions  a  case  in  which 
"  two  boys"  being  at  play,  one  had  an  apple  thrust  into  his  mouth, 
producing  a  double  dislocation ;  and  Nelaton  saw  the  same  accident 
in  an  old  man  of  seventy-two  years,  who  was  toothless. 

This  comparative  immunity  in  youth  and  old  age  has  been  ascribed 
to  certain  peculiarities  in  the  form  of  the  jaw  at  these  periods  of  life. 
Nelaton  attributes  its  more  frequent  occurrence  in  middle  life  to  the 
great  length  and  strong  anterior  inclination  of  the  coronoid  process. 

In  a  majority  of  cases  the  direct  or  immediate  cause  has  seemed  to 
be  muscular  action  alone.  Malgaigne  found  this  cause  to  prevail  in 
twenty-five  out  of  forty  cases;  and  of  the  twenty-five  cases  fifteen 
were  occasioned  by  gaping,  five  by  convulsions,  four  by  vomiting,  and 
one  by  rage.  Dr.  Physick,  of  Philadelphia,  found  both  condyles  dis- 
located in  a  woman  in  consequence  of  the  violent  gesticulation  of  her 
jaw  while  scolding  her  husband.  But  in  a  more  remarkable  case  still, 
this  surgeon  found  the  jaw  dislocated  after  recovery  from  a  profuse 
salivation,  and  of  the  cause  of  which,  or  the  time  of  its  occurrence, 
the  patient,  a  young  girl,  could  give  no  account,  Dr,  Physick  made 
several  ineffectual  attempts  at  reduction,  and  only  succeeded  at  last 
after  he  had  made  her  completely  intoxicated  with  ardent  spirits,^ 

'  Robert,  Journal  de  Cliir.,  1844. 

2  Physick,  Dorsey's  Elements  of  Surgery,  vol.  i.  p.  203.     Philadelphia,  1813. 


502  DISLOCATIONS    OF    THE    LOWER    JAW. 

Dr.  E,  Andrews,  of  Michigan,  found  both  condyles  dislocated  by  a 
lobelia  emetic.  The  patient  had  often  taken  these  emetics  before,  and 
had  frequently  experienced  a  sensation  "of  catching"  at  the  joint,  but 
the  jaw  had  always  until  this  time  resumed  its  position  spontaneously.^ 

Among  the  causes  from  outward  violence,  the  introduction  of  some 
foreign  body  into  the  mouth,  and  the  extraction  of  teeth,  occupy  the 
most  important  place.  In  fifteen  cases,  seven  were  from  the  former 
and  six  from  the  latter  cause. 

My  former  pupil.  Dr.  A-  W.  Gilbert,  has  related  a  case  which  came 
under  his  own  observation,  produced  by  a  similar  cause.  During  his 
apprenticeship  with  Dr.  Parsons,  a  dentist,  he  was  requested  to  insert 
a  set  of  teeth  for  a  young  man  residing  in  Cattaraugus  Co.,  N.  Y.,  and 
while  opening  his  mouth  to  take  an  impression  of  his  gums,  he  dislo- 
cated "both  condyles  forwards,  under  the  zygomatic  arches;"  but  so 
perfectly  were  the  muscles  relaxed,  that  he  immediately  reduced  them, 
without  the  least  difficulty,  by  placing  his  thumbs  as  far  back  as  pos- 
sible upon  the  molar  teeth,  depressing  the  back  part  of  the  jaw,  and 
at  the  same  moment  elevating  the  chin.^ 

Prof.  James  Webster,  of  Kochester,  N.  Y.,  dislocated  the  jaw  of  a 
lady  while  attempting  to  pry  out  a  root  of  one  of  the  molars. 

Pathology. — In  order  that  we  may  better  understand  the  pathology 
of  this  accident,  it  will  be  proper  to  say  a  few  words  in  relation  to  the 
anatomy  of  the  temporo-maxillary  articulation  and  the  other  parts 
concerned  in  the  dislocation  now  under  consideration. 

The  articulation  is  formed  by  the  condyloid  process  of  the  inferior 
maxilla  and  the  glenoid  fossa  of  the  temporal  bone,  in  front  of  which 
fossa,  and  at  the  root  of  the  zygomatic  arch,  is  a  slight  elevation,  called 
the  articular  eminence.  Between  the  joint  surfaces,  both  of  which  are 
covered  with  cartilage  of  incrustation,  is  placed  an  interarticular  car- 
tilage, which  divides  the  joint  into  two  cavities,  one  corresponding  to 
the  condyle  of  the  inferior  maxilla,  and  the  other  to  the  glenoid  fossa, 
each  of  which  is  furnished  with  a  distinct  synovial  membrane. 

Properly  there  is  but  one  ligament — namely,  the  external  lateral — 
which  passes  from  the  outer  surface  of  the  articular  eminence  to  the 
corresponding  surface  of  the  neck  of  the  condyle.  What  is  called  the 
internal  lateral  ligament  arises  from  the  apex  of  the  spinous  process  of 
the  sphenoid  bone,  and  is  inserted  into  the  margin  of  the  dental  fora- 
men, and  has  therefore  no  immediate  connection  with  the  articulation, 
although  it  tends  to  strengthen  the  joint.  The  same  is  true  of  the 
stylo-maxillary  ligaments. 

The  lower  jaw  is  drawn  upwards,  or  closed  upon  the  upper  jaw  by 
the  action  of  the  temporal,  masseter,  and  internal  pterygoid  muscles ; 
it  is  drawn  downwards  by  the  action  of  the  digastricus,  mylo-hyoideus, 
and  genio-hyoglossus  muscles ;  forwards  by  a  few  fibres  of  the  masseter 
and  by  the  external  pterygoid  muscles;  and  laterally  by  the  alternate 
action  of  the  external  and  internal  pterygoid  muscles. 

When  the  mouth  is  open  to  its  utmost  extent,  the  maxillary  condyle 

'  Andrews,  Peninsular  Journ.  Med.,  vol.  iii.  p.  101.     1855. 

2  Gilbert,  Thesis  on  Dislocation  of  the  Inf.  Max.     University  of  Buffalo,  1858. 


DOUBLE    OE    BILATEKAL    DISLOCATION. 


503 


rises  upon  the  articular  eminence  until  it  rests  upon  its  very  summit. 
Indeed,  it  is  probable  that  in  most  persons  it  advances  rather  in  front 
of  the  centre  of  the  eminence;  so  that  in  order  to  become  actually  dis- 
located it  only  needs  that  the  capsule  shall  be  somewhat  relaxed,  or 
that  it  shall  actually  give  way  in  front,  when  the  condyles  slide  for- 
wards and  occupy  a  position  directly  in  front  instead  of  behind  this 
eminence. 

It  is  easy  to  comprehend  how  the  combined  action  of  the  two  ex- 
ternal pterygoid  muscles,  with  a  portion  of  the  fibres  of  the  masseter, 
may  alone  produce  the  dislocation  when  the  mouth  .is  wide  open,  and 
especially  when,  in  consequence  of  a  slight  blow  upon  the  chin,  the  an- 
terior portion  of  the  capsule  becomes  lacerated;  for  it  must  be  noticed 
that  the  ascending  ramus,  with  its 
prolonged  condyloid  process,  con- 
stitutes a  lever  of  the  first  kind, 
in  which  the  temporal  muscle, 
attached  to  the  coronoid  process, 
the  masseter,  and  even  the  mas- 
toid process,  constitute  the  ful- 
crum, the  anterior  portion  of  the 
capsule,  the  weight,  and  the  force 
acting  against  the  front  of  the 
chin,  the  power. 

In  this  position  of  the  condyle, 
drawn  upwards  and  forwards  by 
the  action  of  the  pterygoid  and 
temporal  muscles,  the  chin  de- 
scends toward  the  neck,  and  the 
coronoid  process  rests  against  the  back  of  the  superior  maxilla,  or 
against  the  malar  bone  at  the  point  of  its  junction  with  the  upper 
maxillary.  The  temporal,  masseter,  and  internal  pterygoid  muscles 
are  very  much  upon  the  stretch,  if  not  more  or  less  lacerated. 

Symptoms. — The  mouth  is  widely  open  and  the  jaw  nearly  immov- 
able. It  has  been  noticed  generally  that,  by  pressure,  the  chin  may  be 
slightly  depressed,  but  that,  owing  probably  to  the  pressure  of  the  coro- 
noid process  against  the  body  of  the  upper  maxilla,  or  against  the 
malar  bone,  it  is  generally  impossible  to  elevate  the  jaw  in  any  degree 
whatever. 

The  jaw  is  also  slightly  advanced;  a  depression,  covering  a  con- 
siderable space,  exists  between  the  auditory  canal  and  the  posterior 
margin  of  the  condyle.  A  slight  fulness  is  observed  in  the  temporal 
fossa,  and  also  upon  the  side  of  the  cheek  in  the  region  of  the  masseter 
muscle. 

Ordinarily  the  patient  suffers  considerable  pain,  but  not  always,  from 
the  pressure  of  the  condyles  upon  the  branches  of  the  temporal  nerves. 
There  is  a  constant  flowing  of  the  saliva  from  the  mouth;  the  patient 
is  unable  to  articulate,  and  even  deglutition  is  performed  with  great 
difficulty. 

Prognosis. — When  the  dislocation  remains  unreduced,  the  lower  jaw 
gradually  approximates  the  upper,  and  its  anterior  projection  sensibly 


Double  dislocation  of  the  Inferior  maxilla. 


504 


DISLOCATIONS    OF    THE    LOWER    JAW. 


Double  dislocation  of  the  inferior  maxilla. 


Fig.  228.  diminishes,  the  saliva  ceases  to  drib- 

ble from  the  mouth,  deglutition  and 
speech  are  restored,  mastication  is 
performed  with  considerable  ease, 
and,  in  short,  the  patient  comes  at 
length  to  experience  no  great  incon- 
venience from  the  displacement. 

Eobert  Smith  relates  the  case  of  a 
woman  whose  lower  jaw  was  dislo- 
cated during  an  epileptic  convulsion. 
She  was  at  the  time  in  one  of  the 
metropolitan  hospitals,  but  the  acci- 
dent was  not  noticed  bj  the  surgeons, 
and  it  remained  ever  afterwards  un- 
reduced. At  the  end  of  a  year  she 
could  close  the  lips  perfectly,  but  was 
able  to  open  the  mouth  only  to  a 
limited  extent;  the  teeth  of  the  lower 
jaw  remained  advanced,  the  involun- 
tary flow  of  saliva  had  ceased,  and 
the  faculty  of  speech  had  been  re- 
gained.^ In  Professor  Webster's  case, 
to  which  I  have  before  referred,  although  the  jaw  was  immediately 
and  easily  reduced,  after  the  lapse  of  several  years,  when  I  saw  the 
lady,  she  still  complained  that  it  hurt  her  whenever  she  ate,  and  that 
she  often  felt  the  condyles  slip  in  their  sockets. 

Eeduction  has  been  accomplished  by  Physick  in  the  case  already 
related  after  the  lapse  of  several  weeks;  Sir  Astley  reduced  a  double 
dislocation  after  one  month  and  five  days,  which  had  been  overlooked 
by  the  surgeon  in  attendance;'"  and  Donovan  succeeded  after  ninety- 
five  days.^ 

Treatment. — Reduction  may  generally  be  accomplished  with  ease  in 
cases  of  recent  luxation,  in  the  following  manner:  The  patient  being 
seated  upon  the  floor  with  his  head  between  the  knees  of  the  operator, 
a  couple  of  pieces  of  cork,  gutta  percha,  or  pine  wood  are  placed  as 
far  back  between  the  molars  as  possible,  when  the  surgeon  seizing 
upon  the  chin  draws  it  steadily  upwards,  taking  care  not  to  draw  it 
forwards  at  the  same  time,  since  by  this  movement  he  would  resist 
the  action  of  the  muscles  which  naturally  tend  to  restore  it  to  place 
whenever  the  condyloid  processes  are  lifted  sufficiently  from  the 
zygomatic  foss«.  Many  surgeons  prefer  to  sit  or  stand  in  front  of 
the  patient,  and  depress  the  condyles  by  means  of  the  thumbs  placed 
inside  of  the  mouth  and  upon  the  tops  of  the  molars.  If  the  thumbs 
are  used  in  this  way,  it  would  be  well  to  protect  them  with  a  piece  of 
leather,  or  to  slip  them  off  from  the  teeth  suddenly  when  the  condyles 
are  gliding  into  their  places,  as  the  muscles  sometimes  close  the  mouth 

'  Robert  Smith,  on  Fractures  and  Dislocations.     Dublin,  1854,  p.  288. 
2  Sir  Astley  Cooper,  on  Disloc.  and  Frac,  Amer.  ed.,  p.  316. 
»  Donovan,  Amer.  Journ.  Med.  Sci.,  Oct.  1842,  p.  470,  from  ] 


May  25,  1842. 


Dublin  Med.  Press, 


SINGLE    OR    UNILATERAL    DISLOCATIONS.  505 

with  sufficient  violence  to  bruise  severely  anything  which  might  at 
this  moment  be  interposed  between  the  teeth. 

The  method  practised  by  Ravaton,  of  simply  lifting  the  chin  gradu- 
ally and  forcibly  toward  the  upper  jaw,  was  essentially  the  same,  but 
far  less  efficient;  for  although  he  placed  nothing  between  the  molars 
to  serve  as  a  fulcrum,  the  backmost  teeth  themselves  must  in  some 
degree  perform  this  service  whenever  the  lower  jaw  being  dislocated 
and  drawn  upwards,  the  chin  is  forcibly  approximated  toward  the 
upper. 

In  other  cases  it  has  been  found  necessary  first  to  disengage  the 
coronoid  process,  by  depressing  the  chin  gently,  and  then  pressing 
backwards  in  the  direction  of  the  articulation  ;  a  method  which  would 
certainly  deserve  a  trial  in  case  of  the  failure  of  that  first  described. 
This  was  the  method  practised  by  Hippocrates. 

A  more  effectual  expedient,  however,  consists  in  reducing  one  side 
at  a  time;  taking  good  care  always  that  the  side  first  reduced  is  not 
reluxated  while  the  attempt  is  being  made  to  reduce  the  other,  a 
thing  which  happened  in  one  of  the  cases  treated  by  Sir  Astley 
Cooper,  and  has  happened  many  times  in  the  practice  of  other  sur- 
geons. 

Finally,  if  all  other  expedients  fail,  we  ought  not  to  hesitate  to 
resort  to  aneesthetics,  nor  indeed  could  any  objection  exist  to  their 
employment  at  any  period  of  the  treatment,  were  it  not  that  in  a  large 
majority  of  cases  the  reduction  is  effected  so  easily  and  promptly  as 
to  render  their  employment  wholly  unnecessary. 

After  the  reduction  is  accomplished,  it  will  be  a  matter  of  wise  pre- 
caution to  sustain  the  jaw  by  a  double-headed  bandage  passed  under 
the  chin,  and  secured  upon  the  top  of  the  head,  so  as  to  prevent  the 
mouth  from  being  accidentally  opened  too  far,  especially  during  sleep, 
since  experience  has  shown  that  a  tendency  to  a  reproduction  of  the 
dislocation  remains  for  some  time.  It  will  be  prudent  to  continue 
these  measures  of  protection  for  at  least  one  week ;  after  which  the 
danger  of  anchylosis  should  be  borne  in  mind,  and  the  extent  of 
passive  motion  should  be  gradually  and  cautiously  increased.  In 
illustration  of  this  tendency  to  reluxation,  Malgaigne  refers  to  the 
case  mentioned  by  Putegnat  of  a  woman  whose  jaw  for  many  years 
became  luxated  at  least  once  a  month ;  but  she  was  always  able  to 
reduce  it  herself. 

§  2.  Single  or  "Unilateral  Dislocations. 

The  causes  of  this  accident  are  in  general  the  same  as  those  which 
produce  double  dislocations,  and  it  occurs  most  often  in  middle  life. 
Tartra  has  seen  one  exceptional  example  in  a  child  only  fifteen 
months  old,  and  Levison  saw  a  case  in  an  old  man  who  had  lost  all 
bis  teeth.' 

Symptoms. — The  mouth  is  open,  but  not  so  widely  as  in  double  dis- 
location; the  jaw  is  nearly  immovable;  the  teeth  are  advanced;  the 

'  Levison,  Boston  Med.  and  Surg.  Jouru.,  vol.  xxxiv.,  1846,  p.  388,  from  London 
Lancet. 

33 


506  DISLOCATIONS    OF    THE    LOWER    JAW. 

condyloid  process  can  be  felt  in  front  of  the  articular  eminence,  leav- 
ing a  depression  in  its  natural  situation,  and  the  coronoid  process  is 
more  prominent  than  in  the  bilateral  dislocation. 

It  will  be  remembered  that  we  have  already  pointed  out  an  impor- 
tant diagnostic  mark  between  a  fracture  of  the  neck  of  the  condyloid 
process  and  a  dislocation  of  one  condyle.  In  the  latter  the  chin  in- 
clines to  the  opposite  side,  while  in  the  former  it  falls  toward  the  side 
upon  which  the  accident  has  occurred.  According  to  Hey,  this  lateral 
deviation  of  the  chin  is  not  always  present  in  dislocations;  and  Eobert 
Smith  mentions  one  case  in  which  the  surgeon  was  misled  by  this 
circumstance  so  far  as  to  attempt  a  reduction  upon  the  left  side  when 
the  dislocation  was  upon  the  right. 

Treatment. — The  same  rules  of  treatment  which  we  have  established 
for  dislocations  of  both  condyles  will  be  applicable  to  the  single  dislo- 
cations, with  only  such  modifications  as  will  be  naturally  suggested  to 
the  surgeon. 

In  the  case  mentioned  by  Levison,  the  dislocation  was  constantly 
recurring  upon  the  left  side;  and  it  was  especially  liable  to  happen 
when  just  awakening  from  sleep.  "He  would  then  pull  his  jaw,  press 
it  backwards,  when,  after  about  half  an  hour's  work,  bang  it  seemed 
to  go,  and  all  was  right  again."  This  old  gentleman  was  finally 
relieved  of  these  annoyances  by  a  band  fastened  under  the  chin.  In 
such  a  case,  an  apparatus  constructed  after  the  same  plan  as  my  lower- 
jaw  fracture  apparatus  might  perhaps  serve  a  useful  purpose. 

§  3.  Conditions  of  the  Jaw  simulating  Luxations. 

There  is  a  condition  of  the  temporo-maxillary  articulation  called  by 
Sir  Astley  Cooper  "subluxation  of  the  jaw,"  in  which  it  is  assumed 
that  the  condyles  slip  before  the  anterior  margins  of  the  interarticular 
cartilages,  and  thus  for  the  time  render  the  jaw  immovable.  No  posi- 
tive evidence,  however,  has  ever  been  presented,  either  by  Sir  Astley 
or  others,  that  any  such  derangement  of  the  joint  apparatus  does  actu- 
ally take  place,  the  opinion  being  based,  not  upon  dissections,  but 
only  upon  the  symptoms  which  are  known  to  accompany  the  accident. 
It  is  quite  probable  that  this  explanation  of  the  phenomenon  in  ques- 
tion is  the  true  one,  yet  it  is  not  impossible  that  it  has  no  relation 
whatever  to  the  interarticular  cartilages,  but  that  it  indicates  a  true 
subluxation  of  the  inferior  maxilla  upon  the  zygomatic  eminences. 

It  occurs  mostly  in  young  people,  and  in  those  of  a  feeble  or  scro- 
fulous diathesis.  Kelaxation  of  the  capsule,  ligaments,  and  muscles 
about  the  joint  may,  therefore,  be  regarded  as  the  principal  predispos- 
ing cause.  The  exciting  causes  are  generally  yawning,  or  biting  upon 
some  very  hard  substance. 

The  symptoms  are  a  sudden  arrest  of  the  motions  of  the  jaw,  with 
the  mouth  about  half  open,  the  arrest  of  motion  being  accompanied 
or  preceded  generally  with  a  sensation  of  slipping  in  one  of  the  arti- 
culations. The  chin  is  slightly  inclined  to  the  opposite  side.  The 
condyle  may  be  felt  somewiiat  advanced  in  its  socket,  and  while  it 
remains  in  this  position  the  patient  experiences  some  pain. 


CONDITIONS    OF    THE    JAW    SIMULATING    LUXATIONS.      507 

Frequently  the  condyle  resumes  its  place  spontaneously,  or  after  a 
slight  lateral  motion  of  the  jaw;  but  at  other  times  it  requires  some 
little  manual  force  to  replace  it. 

I  have  myself,  during  several  years  of  my  early  life,  while  pursuing 
ray  studies  at  college,  experienced  this  accident  many  times.  It  was 
peculiarly  prone  to  occur  in  the  morning,  and  it  became  necessary 
that  I  should  eat  with  some  care  at  my  first  meal.  Sometimes  the 
locking  of  the  jaw  was  upon  the  right  and  sometimes  upon  the  left 
side;  it  was  always  painful.  Generally  the  condyle  was  made  to  fall 
into  place  by  a  voluntary  lateral  motion  of  the  jaw,  but  occasionally 
I  was  obliged  to  press  gently  against  the  chin  with  my  hand.  I  never 
adopted  any  measures  to  remove  the  predisposition,  but  as  I  became 
older  the  annoyance  gradually  ceased. 

Benevoli,  in  a  dissertation  published  at  Florence,  Italy,  in  the  year 
1747,  describes  another  condition  very  analogous  to  this  which  we 
have  now  described,  but  which  evidently  depended  upon  a  contrac- 
tion of  the  muscles.  A  priest  having  opened  his  mouth  very  widely 
in  gaping,  found  himself  unable  to  close  it.  A  surgeon  who  was 
called  diagnosticated  a  dislocation  of  the  jaw,  and  attempted  to  reduce 
it,  but  failing,  Benevoli  was  called,  who,  observing  "that  the  jaw  was 
not  absolutely  immovable,  that  the  articulations  were  not  separated, 
and  that  the  chin  did  not  incline  outwards  or  toward  the  sternum," 
concluded  that  it  was  only  a  contraction  of  the  depressing  muscles. 
He  therefore  prescribed  fomentations  and  oily  unctions.  The  same 
night  the  temporal  muscles  had  acquired  the  size  of  a  couple  of  eggs, 
from  contraction,  but  the  next  day  the  patient  could  shut  his  mouth, 
and  by  the  following  day  the  tumefaction  of  the  temporal  muscles 
had  also  disappeared,  and  the  restoration  of  the  functions  of  the 
mouth  was  complete. 

Malgaigne,  to  whom  I  am  indebted  for  the  above  case,  relates  two 
others,  one  in  the  person  of  the  surgeon  Mothe,  and  the  other  in  a 
young  man  who  was  sufi'ering  from  paralysis  and  spasmodic  contrac- 
tions of  the  muscles.  Mothe  observes  that  it  had  occurred  to  him 
very  often,  and  that  it  still  continued  to  happen  sometimes,  that  when 
he  gaped  pretty  widely,  the  genio-hyoid  and  mylo-hyoid  muscles 
contracted  with  so  much  force  as  to  render  it  impossible  for  him  to 
close  his  mouth ;  these  muscles  being  thus  in  a  state  of  cramp,  their 
bellies  became  hard  under  the  chin,  and  so  painful  that  he  was 
obliged  immediately  to  press  upwards  against  the  under  surface  of 
the  chin  in  order  to  oppose  their  action.  This  condition  would  last 
from  one  to  three  minutes,  and  was  relieved,  generally,  by  frictions 
made  with  the  hand  over  the  contracted  muscles.  Sometimes  he 
actually  believed  that  the  lower  jaw  was  dislocated,  although  the 
result  always  convinced  him  that  it  was  not. 


508  DISLOCATIONS    OF    THE    SPINE, 


CHAPTER   III. 

DISLOCATIONS  OF  THE  SPINE. 

Delpech  and  Abernethy  denied  the  possibility  of  a  dislocation  of 
the  spine,  either  in  the  cervical,  dorsal,  or  lumbar  region,  without  the 
concurrence  of  a  fracture. 

Says  Sir  Astley  Cooper:  "I  have  never  witnessed  a  separation  of 
one  vertebra  from  another  through  the  intervertebral  substance,  with- 
out fracture  of  the  articular  processes;  or,  if  those  processes  remain 
unbroken,  without  a  fracture  through  the  bodies  of  the  vertebrae." 
He  would  not,  however,  be  understood  to  deny  the  possibility  of  a 
dislocation  of  the  cervical  vertebrae,  their  articular  processes  being 
placed  more  obliquely  than  those  of  the  other  vertebrae. 

The  accident  is,  no  doubt,  exceedingly  rare,  at  least  without  the 
complication  of  a  fracture,  and  it  is  not  improbable  that  the  actual 
number  is  smaller  than  the  reported  examples  would  indicate.  Those 
who  make  autopsies  do  not  always  perform  their  duties  with  that 
exact  fidelity  which  might  be  necessary  to  determine  so  nice  a  point 
as  a  fracture  of  an  oblique  process,  and  it  is  quite  likely  that  the  cir- 
cumstance may  have  been  overlooked  in  some  cases ;  but  a  consider- 
able number  of  well-authenticated  examples  of  simple  dislocations  of 
cervical  vertebrae-  have  accumulated  within  the  last  fifty  years.  The 
reported  examples  of  simple  dislocations  of  the  other  vertebrae  are 
not  so  numerous,  nor  as  well  attested. 

The  causes  are  in  general  the  same  with  those  which  produce  frac- 
tures of  the  vertebrae,  such  as  falls  upon  the  head,  feet,  or  back,  and 
violent  flexions  of  the  spine  backwards  or  to  the  one  side  or  the  other. 

Several  examples  are  recorded  of  "  spontaneous"  dislocations,  the 
result  of  some  morbid  changes  in  the  bones  or  in  the  ligaments  of  the 
spinal  column;  which  accidents  seem  to  belong  more  properly  to 
general  treatises  upon  surgery. 

The  symptoms,_  also,  partake  of  the  same  general  character  with 
fractures  ;  the  accident  being  accompanied  with  more  or  less  complete 
paralysis  of  those  portions  of  the  body  which  receive  their  nervous 
supply  from  below  the  point  at  which  the  dislocation  has  occurred ; 
the  spinal  column  presenting  at  the  seat  of  displacement  an  angular 
projection  or  some  form  of  irregularity;  and  the  distortion  being 
attended  with  pain,  especially  when  an  attempt  is  made  to  move  the 
body. 

In  very  many  cases  the  symptoms  are  so  nearly  like  those  presented 
in  a  case  of  fracture,  that  the  diagnosis  is  rendered  exceedingly  diffi- 
cult. The  presence  or  absence  of  crepitus  may  aid  in  the  diagnosis, 
and  yet  it  is  well  understood  that  this  symptom  is  often  absent  in 


DISLOCATIONS    OF    THE    LUMBAR    VERTEBRA.  509 

simple  fractures,  and  that  it  may  be  present  in  all  those  examples  of 
dislocation  which  are  accompanied  with  a  fracture  of  an  oblique  pro- 
cess, or  of  any  other  portion  of  the  vertebrae,  which  class  of  examples 
constitutes  a  large  majority  of  the  whole  number. 

There  is  usually  present,  however,  in  the  dislocation,  whether  partial 
or  complete,  a  peculiar  fixedness  or  rigidity  of  the  spine,  which  serves 
to  distinguish  this  accident  from  a  fracture  of  the  spine  as  plainly  as 
the  preternatural  rigidity  of  the  limb  in  dislocations  of  the  long  bones, 
serves  to  distinguish  these  accidents  from  fractures  of  the  same  bones. 
The  head  or  upper  portion  of  the  spinal  column  is  bent  forwards,  or 
backwards,  or  more  commonly  to  one  side,  and  in  this  position  it 
remains  immovably  fixed  until  the  reduction  is  accomplished.  Some- 
times, also,  the  surgeon  may  feel  distinctly  the  lateral  deviation  of 
the  spinous  process,  and,  in  the  neck,  the  transverse  processes  become 
an  important  guide  in  the  diagnosis. 

After  these  few  general  remarks,  I  shall  proceed  to  speak  of  disloca- 
tions of  the  spine  in  the  same  order  in  which  I  have  treated  of  fractures 
of  the  spine. 

§  1.  Dislocations  op  the  Lumbar  Vertebra. 

Sir  Astley  Cooper  plainly  intimates  that  he  does  not  believe  a  dis- 
location can  occur  in  either  the  dorsal  or  lumbar  resrion  without  the 
concurrence  of  a  fracture,  and  Boyer  afi&rms  positively  that  it  is 
"entirely  impossible." 

Without  wishing  ourselves  to  insist  upon  the  actual  impossibility 
of  these  accidents,  we  are  prepared  to  affirm  that  no  well-authenticated 
case  has  yet  been  reported ;  at  least  of  a  complete  dislocation,  unac- 
companied with  a  fracture  of  the  articulating  apophyses.  We  can 
even  conceive  it  possible  that  a  lumbar  vertebra  may  be  dislocated 
forwards  or  backwards,  and  that  a  dorsal  vertebra  may  be  dislocated 
laterally,  without  a  fracture  ;  yet  we  hardly  think  either  of  these  events 
probable.  What  we  urge,  however,  is  that  no  evidence  appears  to  be 
furnished  that  such  a  dislocation  has  actually  occurred. 

Cloquet  mentions  the  case  of  a  "  tiler"  who  fell  from  the  roof  of  a 
house  backwards,  and  dislocated  one  of  the  lumbar  vertebrae.  This 
patient  lived  many  years  after  the  accident,  and  at  the  autopsy  it  was 
found  that  the  second  lumbar  vertebra  had  been  luxated  to  the  right 
by  a  movement  of  rotation  about  the  left  articular  process,  the  two 
oblique  processes  of  the  left  side  preserving  their  connection,  while 
those  of  the  right  were  separated  quite  half  an  inch.  The  right  verte- 
bral plate  was  broken,  and  the  canal  of  the  vertebra  was  thus  thrown 
open  and  widened.^ 

Dupuytren  says  that  a  man  was  crushed  by  the  falling  of  a  bank  of 
earth  upon  his  loins,  when  in  the  act  of  bending  forwards.  On  the 
third  day  he  was  brought  to  Hotel  Dieu,  when  it  was  observed  that 
his  lower  extremities  were  completely  paralyzed;  and  that  there 
existed  in  the  upper  part  of  the  lumbar  region  a  hard  tumor,  by  pres- 

'  Cloquet,  Malgaigne,  from  Journ.  des  DiflFormites  de  Maisonabe,  torn.  i.  p.  453. 


510  DISLOCATIONS    OF    THE    SPINE. 

sure  upon  which  a  crepitus  was  manifest.  A  second  tumor  could  be 
distinctly  felt  in  front  through  the  abdominal  parietes,  and  the  length 
of  the  spine  was  evidently  diminished.  This  man  died  on  the  sixth 
day  frorn  a  gradual  asphyxia.  When  the  body  was  examined  it  was 
found  that  the  last  dorsal  and  first  lumbar  vertebrae  had  been  pushed 
forwards  more  than  one  inch,  lacerating  the  spinal  marrow,  breaking 
the  transverse  and  oblique  processes  of  the  last  dorsal  and  first  two 
lumbar  vertebrse,  and  tearing  off  a  small  fragment  of  the  body  of  one 
of  the  vertebree  where  the  intervertebral  substance  adhered  to  it.' 

These  are  all  the  cases  of  dislocation  of  the  lumbar  vertebrje  of 
which  I  am  able  to  find  any  record.  Both  were  accompanied  with 
fractures.  In  neither  case  was  any  attempt  made  to  reduce  the  dis- 
locations. In  the  second,  it  is  scarcely  probable  that  any  means  could 
have  been  employed  which  would  have  succeeded  in  restoring  the 
bones  to  their  places;  nor  is  it  probable  that  if  the  bones  had  been 
restored  to  place,  the  patient  would  have  survived  the  accident  a 
day  longer,  probably  not  so  long.  The  cord  was  greatly  lacerated, 
and  the  diaphragm  torn  up  and  displaced,  rendering  a  recovery  almost 
impossible. 

In  the  first  example,  where  the  dislocation  was  less  complete,  and 
the  complications  less  grave,  could  reduction  have  offered  any  reason- 
able chance  for  relief?  By  extension,  combined  with  a  movement  of 
rotation  in  a  direction  opposite  to  that  in  which  the  displacement  had 
taken  place,  it  is  possible  that  a  reduction  might  have  been  accom- 
plished. The  attempt  certainly  would  have  been  justifiable ;  but  since 
the  man  lived  "many  years"  without  the  reduction,  it  is  doubtful 
whether  the  result  of  a  reduction  would  have  been  more  fortunate, 

§  2.  Dislocations  op  the  Dorsal  Yertebr^e. 

Malgaigne  enumerates  twelve  examples  of  dislocations  of  the  dorsal 
vertebrae.  I  have  found  reported  by  American  surgeons,  at  dates  too 
recent  to  have  been  included  in  his  analysis,  two  other  examples  ;  but 
of  this  number  only  three  are  claimed  to  have  been  simple  dislocations, 
unaccompanied  with  fracture.  One  of  the  fourteen  was  a  dislocation 
of  the  fifth  dorsal  vertebra  upon  the  sixth,  one  of  the  eighth,  two  of  the 
ninth,  five  of  the  eleventh,  and  five  of  the  twelfth.  The  relative  fre- 
quency of  their  occurrence  in  the  different  vertebrae  corresponding 
with  the  observation  of  Weber,  as  to  the  points  of  the  spinal  marrow 
which  allow  of  the  greatest  freedom  of  motion,  and  are  consequently 
most  liable  to  dislocations.  The  direction  of  the  displacement  in  ten 
cases  was  observed  to  be  six  times  forwards,  twice  backwards,  and 
twice  to  the  one  side. 

Two  of  those  which  were  unaccompanied  with  fracture,  occurring 
respectively  in  the  tenth  and  sixth  dorsal  vertebra,  were  examples  of 
a  dislocation  forwards,  and  the  third,  belonging  to  the  ninth  vertebra, 
was  a  dislocation  backwards.  A  lateral  luxation  without  fracture  has 
not  been  recorded.     It  is  worthy  of  remark,  also,  that  these  three 

'  Dupuytren,  Injuries  and  Dis.  of  Bones,  Syd.  ed.  p.  340. 


DISLOCATIONS    OF    THE    DORSAL    VERTEBRJi;.  511 

examples,  being  all  which  our  science  up  to  this  moment  possesses, 
have  happened  in  the  experience  of  the  same  surgeon.^ 

A  moment's  consideration  of  the  anatomy  of  these  processes  will 
render  it  apparent  that  even  a  partial  luxation  forwards  without  a  frac- 
ture of  the  oblique  apophyses  is  impossible,  and  that  in  the  direction 
backwards  the  luxation  can  only  occur  to  the  extent  of  about  one- 
quarter  of  an  inch,  constituting  only  a  species  of  articular  diastasis, 
without  breaking  off  the  articulating  apophyses  of  the  lower  corre- 
sponding vertebra.  The  first  two  examples,  therefore,  notwithstanding 
they  have  been  received  without  question  by  Malgaigne,  I  shall  un- 
hesitatingly reject.  The  third,  which  alone  carries  evidence  of  its 
having  been  correctly  reported,  and  which  was  only  a  partial  disloca- 
tion, is  related  as  follows:  "A  mason  having  fallen  from  a  height  in 
such  a  manner  as  that  the  lower  part  of  his  back  struck  upon  the 
angle  of  the  upper  step  of  a  ladder,  died  on  the  following  day.  After 
death  it  was  observed  that  the  spinous  processes  of  the  dorsal  vertebrse 
were  prominent  down  to  the  tenth;  and  that  the  tenth  process  Avith  all 
of  the  processes  below  were  depressed.  It  was  also  noticed  that  this 
depression,  very  marked  when  the  trunk  was  thrown  backwards, 
gradually  diminished  and  finally  disappeared  altogether  when  the 
body  was  bent  forwards.  On  removing  the  soft  parts  it  was  found 
that  the  ligaments  were  extensively  torn  asunder  and  detached,  so  as 
to  permit  the  articulating  apophyses  of  the  tenth  vertebra  to  be  carried 
into  contact  with  the  back  of  the  ninth.  The  spinal  marrow  had  un- 
dergone no  visible  alteration."^ 

Malgaigne  thinks  he  has  once  observed  the  same  thing  on  a  living 
subject,  and  that  by  simply  bending  the  body  forwards  he  accom- 
plished the  reduction  and  effected  a  perfect  cure,  except  that  a  slight 
curvature  remained  at  the  point  of  injury. 

Among  the  cases  reported  as  having  been  complicated  with  fracture, 
the  following  example,  reported  by  Dr.  Graves,  of  New  Hampshire,  to 
Dr.  Parker,  of  this  city,  possesses  unusual  interest: — • 

On  the  second  day  of  Jan.,  1852,  a  man,  set.  25,  was  struck  on  the 
back  while  in  a  stooping  posture  by  a  falling  mass  of  timber,  causing 
a  dislocation  of  the  last  dorsal  upon  the  first  lumbar  vertebra.  His 
lower  extremities  were  completely  paralyzed,  and  priapism  continued 
for  several  hours.  The  surgeon  determined  to  make  an  attempt  at 
reduction,  and  for  this  purpose  he  placed  the  patient  upon  his  face,  and 
secured  a  folded  sheet  under  his  armpits  and  another  around  his  hips, 
directing  four  strong  men  to  make  extension  and  counter-extension  by 
these  sheets.  Chloroform  was  administered,  and  when  the  patient  was 
com.pletely  under  its  influence  the  extending  and  counter-extending 
forces  were  applied,  and  in  a  few  minutes  the  vertebrae  glided  into 
place  with  a  distinct  bony  crepitus.  The  restoration  of  the  line  of 
the  vertebral  column  was  found  to  be  nearly  but  not  quite  perfect. 

On  the  sixteenth  day  he  began  to  have  slight  sensations  in  his  feet, 
and  at  the  end  of  six  or  eight  weeks  he  was  able  to  control  the  evac- 

'  Melchiori,  Gaz.  Medica,  stati  sardi,  1850.  «  Melchiori,  Ice.  cit. 


512  DISLOCATIONS    OF    THE    SPINE. 

uations  from  the  bladder  and  rectum.  Several  months  later  he  had 
recovered  so  completely  as  to  walk  with  only  the  aid  of  a  cane.' 

I  know  of  only  one  similar  case.  Rudiger  has  published  an  account 
of  a  dislocation  obliquely  backwards  and  to  the  right  side,  which 
occurred  at  the  same  point  in  the  spinal  column.  The  subject  was  a 
musketeer,  who  had  been  struck  upon  his  back  by  a  falling  wall 
which  he  was  endeavoring  to  pull  down.  Rudiger  laid  him  upon  his 
belly,  and  by  the  assistance  of  others  he  was  able,  but  not  without 
causing  pain,  to  reduce  the  bones.  Immediately,  however,  when  the 
extension  was  discontinued,  the  action  of  the  muscles  caused  the  dis- 
placement to  recur.  The  surgeon  then  directed  four  men  to  make 
extension,  while  another  man  retained  the  bones  in  place  by  pressing 
upon  them  with  his  hands.  After  several  hours  this  method  of  pres- 
sure was  replaced  by  a  board  underlaid  with  compresses  and  sustain- 
ing a  weight  of  more  than  fifty  livres.  On  the  following  day  it  was 
found  sufficient  to  bind  compresses  over  the  projecting  bone,  and  in 
this  condition  the  patient  remained  fifteen  days ;  during  all  of  which 
time  he  lay  upon  his  belly  with  his  shoulders  more  elevated  than  his 
pelvis.  On  the  twentieth  day  he  could  lie  upon  his  back,  and  in 
about  six  weeks  he  was  so  completely  restored  as  to  be  able  to  pursue 
his  trade  as  before  !*  This  is  certainly  a  very  extraordinary  case, 
whether  considered  in  reference  to  the  means  employed  to  restore  the 
bones  to  place,  or  to  its  results ;  and  if  the  statements  are  to  be  re- 
ceived at  all,  it  must  be  with  some  hesitation  and  allowance. 

On  the  other  hand,  we  are  able  to  present  at  least  one  example  in 
which,  although  no  reduction  has  been  accomplished,  the  patient  has 
survived  the  accident  many  years;  yet  it  must  be  admitted  that  his 
recovery  is  far  from  having  been  as  complete  as  in  the  two  cases  just 
mentioned. 

Joseph  Stocks,  ast.  11,  in  the  spring  of  1826,  was  crushed  under  the 
body  of  an  ox-cart  in  such  a  manner  as  to  produce  a  dislocation  of 
the. last  dorsal  from  the  first  lumbar  vertebra,  causing  immediately 
almost  complete  paralysis  of  all  the  parts  below.  This  young  man 
was  seen  by  Dr.  Swan,  of  Springfield,  Mass.,  in  the  summer  of  1834,  at 
which  time  he  was  occupied  as  a  portrait-painter.  His  lower  extremi- 
ties remained  paralyzed  and  of  the  same  size  as  at  the  time  of  the 
receipt  of  the  injury.  He  was  unable  to  sit  erect,  owing  to  the  mobility 
of  the  spine  at  the  seat  of  dislocation,  and  he  had  therefore  lain  con- 
stantly upon  his  side.  The  upper  portion  of  his  body  was  well  de- 
veloped, and  his  intellectual  faculties  were  of  a  high  order.^ 

It  is  not,  however,  with  a  life  of  perpetual  deformity  that  the  two 
examples  of  reduction  already  described  are  to  be  contrasted.  A  result 
so  fortunate  as  this,  where  the  bones  remained  unreduced,  is  unique;  in 
all  the  other  cases  reported  the  patients  died  miserably  after  periods 
ranging  from  a  few  days  to  one  year  or  a  little  more. 

Charles  Bell  has  related  the  case  of  an  infant  who  was  run  over 
by  a  diligence,  and  who  died  thirteen  months  after  the  accident.     On 

»  Graves,  N.  T.  Journ.  Med.,  Marcli,  1852,  p.  190. 

2  Rudiger,  Journ.  de  Chir.  de  Desault,  torn.  iii.  p.  59. 

3  Swan,  Bost.  Med.  and  Surg.  Journ.,  vol.  xxii.  p.  102,  March,  1840. 


DISLOCATIONS    OP    SIX    LOWER    CERVICAL    VERTEBRiE.      513 

examination  after  death,  the  last  dorsal  vertebra  was  found  to  be 
completely  luxated  backwards  and  to  the  left,  upon  the  first  lumbar 
vertebra.^ 

With  these  facts  before  us,  I  think  we  cannot  hesitate,  when  the 
nature  of  the  accident  is  fully  made  out,  and  especially  when  the  dis- 
location has  occurred  in  the  lower  dorsal  vertebrae,  to  attempt  the 
reduction  by  forcible  extension,  united  with  judicious  lateral  motion, 
or  with  a  certain  amount  of  direct  pressure  upon  the  projecting  spines. 

§  3.  Dislocations  of  the  Six  Lower  Cervical  Yertebr^. 

It  is  much  more  common  to  meet  with  simple  luxations  of  the  ver- 
tebrae, of  the  neck  uncomplicated  with  fractures,  than  of  either  of  the 
other  vertebral  divisions.  This  is  doubtless  owing  to  the  greater 
extent  of  motion  which  their  articulating  surfaces  enjoy. 

They  may  be  dislocated  forwards  or  backwards.  The  forward  lux- 
ation may  be  complete  or  incomplete ;  with  both  sides  equally  advanced 
("  bilateral"  of  Malgaigne),  or  one  of  the  articulating  apophyses  may  be 
dislocated  forwards,  leaving  the  opposite  apophysis  in  its  place  ("  uni- 
lateral" of  Malgaigne). 

Schranth"  has  collected  twenty-four  examples  of  luxation  of  the 
cervical  vertebree,  of  which  four  are  recorded  as  dislocations  forwards, 
two  back,  and  six  to  the  one  side  or  the  other.  Three  of  this  number 
were  dislocations  of  the  atlas,  two  were  dislocations  of  the  second 
vertebra,  five  of  the  fourth,  two  of  the  fifth,  two  of  the  sixth,  and 
one  of  the  seventh.     In  the  other  cases  the  seat  was  not  stated. 

Malgaigne  has  brought  together  forty-five  examples ;  of  which 
twenty-one  were  complete  forward  luxations,  nine  incomplete  forward 
luxations,  nine  unilateral  and  forwards,  and  four  were  backward 
luxations.  Three  were  dislocations  of  the  second  vertebra  upon  the 
third,  four  were  dislocations  of  the  third  vertebra,  ten  of  the  fourth, 
eleven  of  the  fifth,  fifteen  of  the  sixth,  and  two  of  the  seventh. 

The  bilateral  forward  luxations  are  generally  caused  by  a  fall  upon 
the  top  and  back  of  the  head,  or  upon  the  top  of  the  head  while  the 
neck  is  very  much  flexed  forwards.  The  unilateral  is  caused  gene- 
rally by  a  direct  blow  upon  the  back  of  the  neck,  the  blow  being 
probably  directed  somewhat  to  one  side  or  the  other.  The  number  of 
backward  luxations  which  have  been  reported  are  too  few  to  enable 
us  to  indicate  very  accurately  the  general  causes,  but  it  seems  proba- 
ble that  they  are  most  often  occasioned  by  a  fall  upon  the  fore  and  top 
part  of  the  head,  received  while  the  neck  is  bent  forcibly  back. 

In  dislocations  of  the  cervical  vertebrae  forwards  the  head  is  usually 
depressed  toward  the  sternum,  in  dislocations  backwards  the  head  is 
thrown  back,  and  in  unilateral  dislocations  the  head  is  turned  over 
one  of  the  shoulders.  Neither  of  these  malpositions  of  the  head  is 
uniformly  present  in  these  several  dislocations,  and  indeed  not  un- 
frequently,  especially  in  case  the  system  is  greatly  shocked  by  the 

'  Charles  Bell,  on  Injuries  of  the  Spine.  1824. 

*  Schranth,  Amer.  Journ.  Med.  Sci.,  May,  1848,  from  Archiv  fiirPhys.  Heilkunde. 


514  DISLOCATIOlSrS    OF    THE    SPINE. 

accident,  the  head  and  neck  assume  a  preternatural  mobility,  and  may 
be  turned  easily  in  any  direction. 

The  spinous  process,  unless  the  patient  is  very  fleshy  or  consider- 
able swelling  has  supervened,  can  easily  be  felt,  and  its  deviations  to 
the  right  or  to  the  left,  forwards  or  backwards,  furnish  us  with  the 
most  valuable  and  important  sign  of  the  dislocation.  Even  the  trans- 
verse processes  may  be  felt  sometimes,  especially  in  the  upper  part  of 
the  neck,  with  sufficient  distinctness  to  render  them  useful  in  the 
diagnosis. 

To  these  circumstances  we  may  add  paralysis  of  the  body  below  the 
seat  of  injury,  with  pain  and  swelling  at  the  point  of  dislocation.  In 
some  cases  also  the  patient  has  himself  distinctly  felt  a  cracking  or 
sudden  giving  way  in  the  neck  at  the  moment  of  the  accident. 

Prognosis. — The  complete  bilateral  luxations,  whether  backwards  or 
forwards,  have  in  most  cases  terminated  fatally  within  a  short  time, 
generally  within  forty-eight  hours.  Unilateral  luxations  are  less 
speedy  in  their  results,  but  when  the  dislocation  remains  unreduced, 
death  generally  takes  place  in  a  month  or  two.  Lente  relates  a  case 
of  incomplete  dislocation  of  the  fifth  cervical  vertebra  backwards, 
unaccompanied  with  fracture,  which  accident  the  patient  survived 
five  days.^  A  patient  of  Roux's  lived  eight  days ;  but  in  the  case 
of  a  second  patient  mentioned  by  Lente,  with  a  complete  luxation, 
without  fracture,  of  the  fifth  vertebra,  the  patient  survived  the  injury 
only  two  hours.^ 

On  the  other  hand,  occasional  examples  are  presented  of  partial  or 
complete  recovery  with  the  luxation  unreduced. 

Horner,  of  Philadelphia,  presented  to  the  class  of  medical  students 
of  the  University  of  Pennsylvania,  in  1842,  a  lad  aet.  10,  who  had  fallen 
a  distance  of  twenty  feet,  alighting  upon  his  head.  He  was  found 
senseless  and  motionless,  with  his  head  bent  under  his  body.  He 
gradually  recovered  from  the  shock,  but  his  neck  was  stiff)  distorted, 
and  motionless,  his  face  being  inclined  downwards  to  the  right  side. 
Two  days  after,  his  "  common  and  accurate  perceptions  returned,  but 
he  was  affected  for  some  time  with  tingling  and  numbness  in  his  left 
arm."  When  presented  to  the  class  the  transverse  processes,  from  the 
fifth  upwards,  were  about  half  an  inch  in  front  of  those  below,  showing 
that  the  left  oblique  process  of  the  fourth  was  dislocated  forwards 
upon  the  fifth.  The  rotary  motions  of  the  neck  could  now  be  exe- 
cuted to  some  extent,  but  much  more  freely  to  the  right  than  to  the 
left.  Professor  Horner  refused  to  make  any  attempt  to  reduce  the 
dislocation.^ 

Dr.  Purple,  of  New  York,  has  reported  a  case  of  what  was  called  a 
dislocation  of  the  fifth  and  sixth  cervical  vertebrae,  producing  complete 
paralysis  of  the  lower  part  of  the  body,  in  which  the  patient  survived 
the  accident  many  years;  but  his  lower  extremities  were  so  useless 
and  cumbersome  as  to  induce  him,  in  the  year  1851,  six  years  after 
the  injury  had  been  received,  to  submit  to  the  amputation  of  both  at 

1  Lente,  New  York  Journ.  Med.,  May,  1850,  p.  284.  «  Lente,  ibid.,  p.  397. 

3  Horner,  Amer.  Journ.  Med.  Sci.,  April,  1843,  from  Med.  Exam. 


DISLOCATIONS    OF    SIX    LOWER    CERVICAL    VERTEBRAE.      515 

the  hip-joint.  In  1852,  having  become  very  intemperate,  he  died,  but 
no  autopsy  was  obtained,  so  that  the  exact  character  of  the  injury  was 
never  ascertained.'  Sanson,  of  Paris,  has  reported  also  a  case  which 
came  under  his  observation  at  Hotel  Dieu,  of  dislocation  of  the  "  third 
cervical  vertebra  backwards,"  from  which,  although  unreduced,  the 
patient  partially  recovered.  The  character  of  this  accident  was  not 
much  better  determined  ;  for,  although  he  felt  a  severe  and  sharp  pain 
at  the  moment  of  the  injury,  which  was  greatly  aggravated  by 
motion,  and  his  head  was  bent  forwards  and  to  the  left,  "  the  chin 
being  fixed  on  the  upper  part  of  the  sternum,"  there  was  no  paralysis 
of  either  the  motor  or  sentient  nerves.  After  the  lapse  of  about  four 
months  he  left  the  hospital,  still  unable  to  lift  his  chin  more  than  four 
inches  from  the  sternum  ;  after  which  he  resumed  his  usual  occupa- 
tions, suffering  no  further  inconvenience  than  what  was  occasioned 
by  the  unnatural  position  of  his  head.^  Notwithstanding  the  authori- 
tative testimony  of  Sanson  that  this  was  a  dislocation  backwards,  one 
cannot  avoid  the  conclusion  that  it  was  either  a  unilateral  subluxa- 
tion, or  perhaps  a  mere  diastasis  of  the  articulation,  or  else  that  it  was 
an  example  of  sprain  of  the  muscles,  and  consequent  contraction  of  one 
set,  or  paralysis  of  the  opposing  set  of  muscles.  It  is  certain  that  it 
was  not  a  complete  luxation;  nor,  since  there  was  no  paralysis  of  the 
body  below  the  point  of  injury,  can  it  be  properly  made  use  of  as  an 
argument  for  non-interference  where  such  paralysis  does  actually  exist. 

Let  us  see  now  what  encouragement  an  attempt  at  reduction  may 
offer,  in  a  case  which  presents  so  little  ground  of  hope  where  the 
reduction  is  not  accomplished. 

Dr.  Spencer,  of  Ticonderoga,  N".  Y.,  relates  that  a  man,  set.  50,  fell 
backwards  from  a  board  fence,  striking  upon  the  superior  and  anterior 
portion  of  his  head,  dislocating  the  second  from  the  third  vertebra  of 
the  neck.  His  head  was  thrown  back  so  far  as  to  prevent  his  seeing 
his  own  body,  and  all  below  the  injury  was  completely  paralyzed. 
Eepeated  attempts  were  made  to  reduce  the  dislocation,  "but  the  trans- 
verse processes  had  become  so  interlocked  that  every  efltbrt  proved 
abortive,"  and  he  died  forty-eight  hours  after  the  injury  was  received.^ 
Gaitskill  also  attempted  reduction  in  a  case  of  dislocation  of  the  seventh 
cervical  vertebra,  but  failed.*  Boyer  failed  in  two  cases.  It  is  related 
by  Petit  Eadel,  that  a  young  patient  at  La  Charite  expired  in  the 
hands  of  the  surgeons,  upon  such  an  attempt  being  made  a  few  days 
after  the  accident;^  and  Dupuytren  says  "  the  reduction  of  these  dislo- 
cations is  very  dangerous,  and  we  have  often  known  an  individual 
perish  from  the  compression  or  elongation  of  the  spinal  marrow  which 
always  attends  these  attempts." 

Dr.  Shuck,  of  Vienna,  relates  that  a  man,  aet.  24,  while  engaged  at 
his  work  on  the  5th  of  Dec.  1838,  twisted  his  head  suddenly  round, 
in  consequence  of  one  of  his  companions  roaring  into  his  ear,  when  he 

'  Purple,  New  York  Journ.  Med.,  May  1853,  p.  319. 

2  Sanson,  Amer.  Journ.  Med.  Sci.,  Feb.  1836,  p.  514  ;  from  Gaz.  des  HSpitaux. 

*  Spencer,  Boston  Med.  and  Surg.  Journ,  vol.  xv.  No.  11. 

*  Gaitskill,  London  Repository,  vol.  xv.  p.  282. 

5  Petit  Radel,  Note  to  Boyer,  Malad.  Chir.,  vol.  v.  p.  118. 


516  DISLOCATIONS    OF    THE    SPINE. 

instantly  felt  something  give  way  in  his  neck,  and  found  it  impossible 
to  move  his  head.  Next  morning  his  head  was  turned  to  the  right 
and  bent  down  toward  the  shoulder.  Every  attempt  to  move  his  head 
caused  great  pain.  He  complained  of  weakness  in  his  right  arm,  but 
all  the  other  functions  of  his  body  were  perfect.  An  attempt  was 
immediately  made  to  reduce  the  dislocation  by  lifting  him  by  the  head, 
but  without  success.  On  the  7th  of  Dec,  the  weakness  and  numbness 
of  the  right  arm  had  increased,  and  the  attempt  to  reduce  the  bones 
was  renewed.  The  patient  was  laid  horizontally  upon  a  bed  ,and  ex- 
tension made  from  the  chin  and  occiput  while  counter -extension  was 
made  from  the  shoulders.  The  force  thus  employed  was  gradually 
increased  until  the  patient  and  assistant  felt  a  snap  as  of  two  bones 
meeting,  when  it  was  found  that  the  head  was  restored  to  its  natural 
position,  and  the  power  of  moving  it  had  returned.  The  next  day  his 
arm  was  more  powerless  than  before,  and  on  the  following  day  he  had 
vertigo,  but  these  symptoms  soon  yielded  to  copious  bleedings,  and  he 
left  the  hospital  cured  on  the  13th. ^ 

Dr.  Hickerman,  of  Ohio,  has  reported  also,  in  the  Ohio  Medical 
Journal,  a  case  of  dislocation  of  one  of  the  cervical  vertebrae,  the 
original  account  of  which  I  have  not  seen,  but  only  an  abridged  state- 
ment published  in  the  Buffalo  Medical  Journal.  By  exploring  the 
pharynx  a  prominence  was  felt  opposite  the  junction  of  the  fourth 
and  fifth  cervical  vertebrae ;  and  the  action  of  the  heart  was  barely  per- 
ceptible. Seizing  the  patient's  head  under  his  left  arm.  Dr.  Hickerman 
in  this  manner  made  traction,  while,  with  the  index  finger  of  the  right 
hand  in  the  patient's  throat,  he  made  firm  pressure  obliquely  upwards, 
backwards,  and  to  the  left;  after  continuing  the  pressure  for  about 
forty  or  fifty  seconds,  the  part  against  which  the  finger  was  placed 
gradually  yet  quickly  receded  in  the  direction  in  which  the  pressure 
was  made,  and  instantly,  as  quickly  indeed  as  the  act  could  be  possibly 
executed,  the  patient  opened  her  eyes,  and  natural  respiration  was  es- 
tablished. She  then  also  immediately  became  conscious  of  what  was 
transpiring  about  her,  and  signified  by  signs,  for  she  was  yet  unable 
to  speak,  that  she  had  suffered  pain  in  the  epigastrium.  Complete 
recovery  took  place.^ 

Schranth  received  under  his  care  a  patient  who  had  a  luxation  of 
the  "  right  transverse  apophysis"  of  the  fourth  cervical  vertebra, 
without  lesion  of  the  spinal  marrow,  which  he  reduced  on  the  seventh 
day.  The  first  attempt  was  unsuccessful ;  but  the  second,  made  with 
great  caution,  by  the  aid  of  four  assistants,  three  of  whom  pulled  the 
head  upwards  while  the  fourth  pressed  with  his  whole  weight  upon 
the  shoulders,  was  completely  successful.  During  the  time  that  the 
traction  was  being  made,  the  head  was  occasionally  rotated  slightly 
and  moved  laterally,  and  at  the  same  moment  the  surgeon  pushed 
firmly  against  the  displaced  apophysis.  The  reduction  was  attended 
with  "various  distinct  crackings  in  the  neck,"  which  were  loud  enough 

>  Shuck,  Amer.  Journ.  Med.  Sci.,  July,  1841,  p.  207. 

2  Hickerman,  Buf.  Med.  Journ.,  vol.  x.  p.  703,  April,  1855. 


DISLOCATION'S    OF    SIX    LOWER    CERVICAL    VERTEBRA.       517 

to  be  heard.  After  some  days  of  repose  he  resumed  his  occupation, 
no  stiffness  remaining  in  the  movements  of  the  neck.' 

Dr.  Edward  Maxson,  of  Geneva,  N.  Y.,  was  called  on  the  28th  of 
Oct.  1856,  to  see  a  child  about  nine  years  old,  who  had  met  with  a 
similar  accident  about  forty  hours  before,  namely  a  dislocation  of  the 
right  articulating  apophysis  of  the  fifth  or  sixth  cervical  vertebra, 
occasioned  by  suddenly  turning  her  head  around  while  at  play.  She 
at  first  complained  only  of  pain  and  inability  to  straighten  the  neck ; 
but  whenever  moved  she  became  faint  and  irritable.  A  short  time 
before  the  surgeon  was  called,  the  mother  had,  in  attempting  to  move 
her  in  bed,  turned  the  face  a  little  more  to  the  left,  when  a  severe 
convulsion  immediately  ensued.  On  examining  the  neck,  Dr.  Maxson 
discovered  the  displacement  of  the  transverse  process.  Having  ad- 
vised the  parents  of  the  danger  necessarily  incident  to  an  attempt  at 
replacement,  and  of  the  probable  consequences  of  its  being  permitted 
to  remain  as  it  was,  they  consented  that  the  trial  should  be  made.  "I 
grasped  the  head,"  says  Dr.  M.,  "with  both  hands,  and  proceeded 
according  to  Desault's  method,  only  I  first  carried  or  turned  the  face 
very  gently  a  little  further  toward  the  left  shoulder,  to,  if  possible, 
disengage  the  process;  then  lifting  or  extending  the  head,  I  turned 
the  face  very  gently  toward  the  right  shoulder,  when  the  difficulty 
was  at  once  overcome,  and  she  exclaimed:  'I  can  move  my  eyes.' 
Her  countenance  soon  acquired  a  more  natural  appearance;  the  faint- 
ness  passed  off;  she  rested  quietly  through  the  night;  had  no  return 
of  the  difficulty,  and  needed  only  an  emollient  anodyne  to  soothe  the 
irritation  and  slight  swelling  which  remained  at  the  point  of  injury."^ 

Rust,^  Wood,  of  this  city,^  and  others,  have  seen  and  reported  simi- 
lar cases  attended  with  like  success. 

So  far  the  cases  of  successful  reduction  which  we  have  described 
are  examples  of  dislocation  of  only  one  of  the  articulating  apophyses, 
and  they  are  sufficiently  numerous  to  establish  the  value  of  the  prac- 
tice. We  have  now  to  relate  a  case  in  itself  unique,  namely,  a  suc- 
cessful reduction  of  a  dislocation  of  the  fifth  cervical  vertebra,  in  which 
both  apophyses  appear  to  have  been  thrown  forwards.  It  occurred 
in  the  practice  of  Dr.  Daniel  Ayres,  of  Brooklyn,  N.  Y.,  and  will  be 
best  understood  by  a  reproduction  of  his  own  published  account  of 
the  case : — 

"E.  K.,  the  subject  of  this  accident,  was  a  laboring  man,  thirty 
years  of  age,  tall  and  muscular,  but  not  fat,  with  a  neck  longer  than 
the  average  among  men  of  equal  height.  On  the  evening  of  the  2d 
of  October  he  became  intoxicated ;  was  brought  home  insensible,  and 
did  not  recover  from  the  combined  effects  of  the  shock  and  his  liba- 
tions until  the  following  morning,  when  he  was  supposed  by  his  wife 
to  be  laboring  under  cold  and  a  stiff'  neck.  She  made  some  domestic 
applications  to  the  affected  part,  and  administered  a  dose  of  cathartic 
medicine.     When  it  was  thought  sufficient  time  had  elapsed  without 

•  Schranth,  Amer.  Journ.  Med.  Sci.,  May,  1848. 

2  Maxson,  Buffalo  Med.  Jonrn.,  Jan.  1857,  p.  476. 

3  Rust,  Clielius,  note  by  Smith. 

*  Wood,  New  York  Journ.  Med.,  Jan.  1857,  p.  13. 


518  DISLOCATIONS    OF    THE    SPINE. 

obtaining  relief,  he  was  seen  by  Dr.  Potter,  of  tbis  city,  and  afterwards 
by  Dr.  Cullen,  both  of  whom  recognized  a  condition  which  was  not 
only  very  unusual,  but  one  which  they  had  never  before  observed.  I 
was  then  requested  to  examine  the  case,  which  I  did  on  the  ninth  day 
after  the  accident.  With  some  assistance  and  great  personal  effort, 
he  was  able  to  get  out  of  bed,  moving  very  slowly  and  cautiously. 
Desiring  to  expectorate,  he  was  obliged  to  get  down  on  his  hands  and 
knees,  which  he  accomplished  with  the  same  deliberation.  When 
seated  in  a  chair,  the  head  was  thrown  back  and  permanently  fixed; 
the  face  turned  upward  with  an  anxious  expression.  The  anterior 
portion  of  the  neck,  bulging  forwards,  was  strongly  convex,  rendering 
the  larynx  very  prominent.  The  integuments  of  this  region  were 
exceedingly  tense  and  intolerant  of  pressure.  The  posterior  portion 
of  the  neck  exhibited  a  sharp,  sudden  angle  at  the  junction  of  the 
fifth  and  sixth  cervical  vertebrae,  around  which  the  integuments  lay 
in  folds.  It  was  difficult  to  reach  the  bottom  of  this  angle  even  with 
strong  pressure  of  the  fingers,  and  of  course  the  regular  line  formed 
by  the  projecting  spinous  processes  was  abruptly  lost.  He  complained 
of  intense  and  constant  pain  at  this  point,  which  was  neither  relieved 
nor  aggravated  by  pressure.  With  difficulty  he  swallowed  small 
quantities  of  liquid,  pausing  after  each  effort,  and  could  not  be  induced 
to  take  solid  food,  since  the  first  attempt  to  do  so  after  the  accident 
was  followed  by  violent  paroxysms  of  coughing  and  choking.  His 
breathing  was  obstructed  and  somewhat  labored,  being  unable  fully 
to  clear  the  bronchia  of  their  secretion.  This,  however,  seemed  rather 
an  effect  of  the  tense  condition  of  the  soft  parts  of  the  neck,  than  the 
result  of  pressure  upon  the  spinal  cord,  since  he  presented  no  evidence 
of  paralysis,  either  of  motion  or  sensation,  in  parts  below  the  neck. 
The  sterno-cleido-mastoid  muscles  of  both  sides  were  felt  quite  soft 
and  relaxed. 

'•But  one  conclusion  could  be  formed  upon  this  state  of  facts,  to 
wit :  that  the  oblique  processes  of  both  sides  were  completely  dislo- 
cated. The  marked  rigidity  of  the  head  seemed  to  preclude  the  pro- 
bability of  fracture  through  the  vertebral  bodies,  and  although  the 
cartilage  might  be  separated  anteriorly,  yet  the  body  not  pressing 
backwards  sufficiently  to  produce  paralysis  of  the  cord,  it  was  hoped 
that  the  posterior  vertebral  ligament  remained  uninjured;  it  was, 
therefore,  determined  to  make  an  effort  at  reduction  on  the  following 
day.  In  addition  to  those  originally  connected  with  the  case,  I  am 
under  obligations  to  Drs.  Ingraham,  Turner,  Palmedo,  G.  D.  Ayres, 
and  a  number  of  other  medical  gentlemen,  who  were  present  by  invi- 
tation, all  of  whom  confirmed  the  diagnosis,  and  rendered  efficient 
services. 

"The  patient  was  placed  upon  a  strong  table,  in  a  recumbent  posi- 
tion, with  a  pillow  resting  under  the  shoulders,  the  head  being  sup- 
ported by  the  hand  during  the  administration  of  chloroform,  of  which 
an  ounce  was  given  before  anaesthesia  ensued.  Counter-extension 
being  made  by  two  folded  sheets  placed  obliquely  across  the  shoulders 
and  properly  held,  the  head  was  grasped  by  one  hand  placed  under 
the  chin,  the  other  over  the  occiput,  and  by  steadily  and  firmly  draw- 


DISLOCATIONS    OF    THE    ATLAS. 


519 


Fig.  229. 


ing  the  head  directly  backwards,  and  then  upwards,  an  attempt  was 
made  at  reduction,  but  failed  for  want  of  sufficient  power.  Dr.  Ingra- 
ham  was  then  requested  to  place  his  hands  immediately  over  my  own 
in  the  same  position  as  before,  and  steady  traction  was  again  made  in 
the  same  direction.  Our  united  strength  was  required  in  drawing 
the  head  backwards  and  upwards  to 
dislodge  the  superior  oblique  processes 
from  their  abnormal  position.  When 
this  was  felt  to  be  yielding  by  Dr. 
Cullen  (who  kept  one  hand  constantly 
at  the  seat  of  dislocation),  Dr.  Potter 
was  directed  to  place  his  hands  under 
our  own,  still  in  position,  and  assist  in 
bringing  the  head  forwards;  at  the 
same  time  the  chest  was  depressed 
toward  the  table.  The  bones  were 
distinctly  felt  to  slip  into  their  places ; 
the  line  of  the  spine  was  instantly  re- 
stored, the  head  and  neck  assuming 
their  natural  position  and  aspect.  As 
soon  as  the  patient  became  conscious, 
he  expressed  himself  ignorant  of  what 
had  taken  place,  but  free  from  pain, 
and,  in  his  own  language,  'all  right.' 
A  bandage  was  arranged  to  support 
the  head  and  keep  it  bent  forwards. 
He  had  an  anodyne  for  two  nights  fol- 
lowing, after  which  no  further  treat- 
ment was  necessary,  and  at  the  end  of 
one  week  he  had  complete  control  over 
the  movements  of  the  head  and  neck. 
Beyond  the  debility  and  emaciation  immediately  dependent  upon 
protracted  fasting  and  loss  of  rest,  he  has  experienced  no  uneasiness 
since  the  operation.  His  appetite  is  now  good,  and  all  the  functions 
perform  their  duty  normally.  In  a  subsequent  inquiry,  to  determine, 
if  possible,  the  cause  of  the  accident,  he  states  that  he  distinctly 
recollects  going  into  a  store  in  Atlantic  Street,  near  the  ferry,  and 
there  having  angry  words  with  an  acquaintance;  that  he  left  the 
store,  and  was  proceeding  up  the  street  (which  is  here  a  rather  steep 
ascent),  when  he  was  violently  struck  from  behind,  over  the  lower 
portion  of  the  neck.  He  likewise  remembers  falling  forwards,  and 
striking  against  some  object,  but  does  not  know  what  it  was,  nor  what 
took  place  until  the  following  morning."^ 


Ayres'  case  of  bilateral  dislocation  of  the 
fifth  cervical  vertebra. 


§  4.  Dislocations  op  the  Atlas. 

Surgeons  have  met  with  several  forms  of  displacement  between  the 
atlas  and  axis.  First,  a  forced  inclination  forwards  of  the  atlas  upon 
the  axis;  in  consequence  of  which  the  body  or  anterior  arch  of  the 


•  Ayres,  New  York  Journ.  Med.,  Jan.  1857,  p.  9. 


520  DISLOCATIONS    OF    THE    SPIXE. 

atlas  is  made  to  recede  from  the  odontoid  process,  and  the  transverse 
ligament  glides  upwards  without  breaking,  so  that  the  extremity  of 
the  odontoid  process  comes  to  occupy  a  position  underneath  or  behind 
the  ligament,  and  thus  presses  upon  the  cord.  It  is  apparent  also  that 
this  form  of  displacement  cannot  occur  without  a  rupture  of  the  ver- 
tical ligaments  which  bind  the  transverse  ligaments  to  the  axis,  nor 
without  a  separation  of  the  atlas  from  the  axis  posteriorly  and  a  rup- 
ture of  the  posterior  atlo-axoidean  ligament.  Second,  a  similar  incli- 
nation of  the  atlas,  accompanied  with  a  rupture  of  the  transverse  and 
superior  vertical  ligaments,  in  consequence  of  which  also  the  odontoid 
process  is  allowed  to  fall  upon  the  cord.  Third,  the  atlas  in  the  same 
position,  with  the  odontoid  process  broken  at  its  base.  Fourth,  the 
atlas  displaced  directly  forwards  or  backwards ;  and  fifth,  a  displace- 
ment of  only  one  articular  process  in  a  direction  forwards. 

We  have  already,  when  speaking  of  fractures  of  the  atlas,  or  of  the 
atlas  and  axis  together,  called  attention  to  several  examples  of  that 
form  of  the  dislocation  which  is  accompanied  with  a  fracture  of  the 
odontoid  process.  The  other  forms  of  dislocation  are  characterized 
by  so  few  symptoms  peculiar  to  themselves,  or  which  can  be  regarded 
as  diagnostic  and  not  already  sufficiently  studied  in  connection  with 
otber  dislocations  of  the  neck,  that  we  shall  not  deem  it  necessary  to 
do  more  than  remind  our  readers  that  if  permitted  to  remain  unre- 
duced a  speedy  and  fatal  issue  is  inevitable,  and  to  point  them  to  a 
couple  of  examples  of  recovery,  after  reduction  has  been  fortunately 
accomplished  ;  for  both  of  which  I  am  indebted  to  Malgaigne.  These 
may  alone  suffice  to  show  that  Dupuytren  was  in  error  when  he 
declared  that  such  accidents  were  wholly  beyond  the  resources  of 
our  art. 

An  old  man  received  upon  his  head  a  bundle  of  hay  cast  from  the 
top  of  a  wagon.  He  fell  with  his  head  bent  forwards  so  that  his  chin 
touched  the  top  of  the  sternum,  and  in  this  position  it  remained 
immovably  fixed ;  all  the  other  portions  of  his  body  preserved  their 
natural  functions.  A  surgeon,  who  was  indeed  the  father  of  Mal- 
gaigne, being  called,  assured  the  patient  that  unless  he  could  give  him 
relief  he  certainly  would  die ;  but  that  inasmuch  as  the  attempt  might 
itself  prove  fatal,  he  ought  at  once  to  put  in  order  his  affairs.  Accord- 
ingly the  man  partook  of  the  sacrament ;  then  the  surgeon  seated  him 
upon  the  ground,  and  placing  himself  at  his  back  with  his  knees 
resting  upon  his  shoulders  for  the  purpose  of  making  counter-exten- 
sion, and  with  a  towel  brought  over  his  own  shoulders  and  under  the 
chin  of  the  patient  for  extension,  he  proceeded  to  act  upon  the  neck  in 
the  direction  of  the  axis  of  the  spine.  The  efforts  were  long  and  pain- 
ful, but  at  last,  while  the  head  was  lifted  as  far  as  possible,  it  was  sud- 
denly drawn  backwards,  and  immediately  it  resumed  its  natural 
direction.  Absolute  quietude  was  enjoined,  and  the  patient  recovered 
in  a  short  time  and  without  any  accident. 

This  patient  was  seen  two  years  after  by  the  younger  Malgaigne,  at 
which  time  no  trace  of  the  accident  remained,  except  an  impossibility 
of  turning  the  head  to  the  right  or  to  the  left. 

The  other  example  is  related  by  Ehrlich,  but  in  this  case  the  dislo- 


DISLOCATIONS    OF    THE    RIBS    FROM    THE    VERTEBRAE.      521 

cation  was  backwards.  A  young  man,  get.  16,  while  carrying  a  sack 
of  flour  up  a  ladder,  fell  backwards,  and  the  sack  falling  over  upon  his 
face  and  head  came  to  the  ground  before  him.  He  was  found  lying 
with  his  head  thrown  back  and  to  the  right,  the  head  resting  upon  the 
scapula  of  this  side,  but  having  so  completely  lost  its  "  solidity"  that 
by  its  own  weight  it  would  fall  from  one  side  to  the  other.  On  the 
front  and  left  side  of  the  neck  there  existed  a  prominence  supposed 
to  be  formed  by  the  atlas;  the  patient  was  unconscious;  the  pulse  was 
scarcely  perceptible,  and  the  whole  body  was  suffering  under  paralysis. 
Ehrlich  directed  the  shoulders  to  be  held  by  one  assistant,  and  the 
head  to  be  drawn  upon  by  another,  while  he  pressed  with  his  own 
hands  forcibly  upon  the  displaced  atlas  from  behind.  After  several 
fruitless  attempts,  the  reduction  took  place,  accompanied  with  a  sound 
distinctly  audible  to  all  of  the  assistants;  the  head  resumed  its  posi- 
tion firmly,  and  the  arms  began  to  move.  The  head  was  afterwards 
maintained  in  place  by  a  bandage.  The  cure  proceeded  rapidly,  and 
after  a  time  no  trace  of  the  injury  remained  but  a  disagreeable  tension 
in  the  nape  of  the  neck  whenever  he  moved  his  head  briskly  to  the 
one  side  or  the  other.^ 

§  5.  Dislocations  or  the  Head  upon  the  Atlas,  or  Occipito-Atloidean 

Dislocations. 

Lassus,  Palletta,  and  Bouisson^  have  each  reported  one  example  of 
this  dislocation.  In  neither  case  was  the  dislocation  complete,  but 
death  occurred  speedily  in  every  instance.  Dariste  exhibited  to  the 
Anatomical  Society  of  Paris,  in  1838,  a  specimen  of  incomplete  luxa- 
tion of  the  occipito-atloidean  articulation,  with  stretching  of  the 
transverse  ligament.  The  patient  from  whom  the  specimen  was  taken 
having  lived  more  than  a  year  after  the  accident,  when  he  died  from 
a  tubercle  in  the  brain.^ 


CHAPTER    IV. 

DISLOCATIONS  OF  THE  RIBS. 

The  ribs  may  be  separated  from  the  bodies  of  the  vertebrae,  from 
the  cartilages  of  the  ribs,  and  from  each  other.  The  cartilages  of  the 
ribs  may  also  be  separated  from  the  sternum. 

§  1.  Dislocations  or  the  Ribs  from  the  Vertebra. 

The  heads  of  the  ribs  are  joined  to  the  bodies  of  the  vertebrae  by 
strong  ligaments.    The  articulations  are  ginglymoid,  admitting  of  mo- 

'  Malgaigne,  Ehrlicli,  Malgaigne,  op.  cit.,  torn.  ii.  p.  334. 
•'  Lassus,  Palletta,  Bouisson,  Malgaigne,  op.  cit.,  p.  330. 

3  Daristc,  Amer.   Jouru.  Med.  Sci.,  Nov.  1838,  p.  237,  from  Archives  Geu.,  May, 
1838. 

34 


522  DISLOCATIONS    OF    THE    EIBS. 

tion  chiefly  in  the  direction  of  the  axis  of  the  spine.  The  mobility 
gradually  increases  as  we  proceed  from  the  first  rib  downward  to  the 
last.     Each  joint  is  furnished  with  a  capsule. 

The  necks  and  tubercles  are  also  united  to  the  transverse  processes 
by  ligaments,  and  the  articulations  are  furnished  with  synovial  cap- 
sules. 

I  am  not  aware  that  any  examples  have  ever  been  reported  of  dis- 
locations of  the  ribs  from  the  transverse  processes. 

Examples  of  dislocation  of  the  heads  of  the  ribs  have  been  mentioned 
by  Ambrose  7ar6,  Bransby  Cooper,  Alcock,  Donne,  Henkel,  Kennedy, 
Buttet,  and  some  others ;  but  most  of  these  reputed  cases  have  not 
borne  the  test  of  a  critical  analysis,  and  while  Yidal  (de  Cassis)  is  in 
doubt  whether  the  claims  of  even  one  have  been  fully  established, 
Boyer  denies  absolutely  its  possibility.  We  see  no  reason,  however, 
to  question  the  authenticity  of  several  of  these  examples. 

The  case  mentioned  by  Bransby  Cooper,  although  very  briefly 
narrated,  leaves  no  room  for  doubt  as  to  its  real  character.  "  Mr. 
Webster,  surgeon  at  St.  Albans,  when  examining  the  body  of  a 
patient  who  had  died  of  fever,  found  the  head  of  the  seventh  rib 
thrown  upon  the  front  of  the  corresponding  vertebra,  and  there 
anchylosed.  Upon  inquiry,  Mr.  Webster  learned  that  this  gentle- 
man, several  years  before,  had  been  thrown  from  his  horse  across  a 
gate,  for  which  accident  he  had  been  subjected  to  the  treatment  usually 
followed  in  fractures  of  the  ribs,  and  there  is  every  reason  to  believe 
that  it  was  at  this  time  the  dislocation  occurred."^ 

These  accidents  seem  to  have  been  generally  occasioned  by  a  fall 
or  a  blow  upon  the  back,  and  the  dislocation  has  been  accompanied, 
usually,  with  a  fracture  of  some  other  rib,  or  of  the  transverse  or 
spinous  processes  of  the  corresponding  vertebrae.  The  head  of  the 
rib  has  always  been  found  to  be  displaced  inwards.  The  lower  ribs, 
including  the  false  and  floating,  are  those  which  have  been  most  fre- 
quently displaced. 

It  would  be  difficult,  if  not  impossible,  during  the  life  of  the  patient, 
to  make  a  positive  diagnosis,  since  the  symptoms  resemble  so  closely 
those  which  accompany  a  fracture  of  the  rib  near  its  posterior  ex- 
tremity. The  nature  of  the  accident  producing  the  dislocation,  the 
depression,  mobility,  and  pain,  are  equally  indicative  of  a  fracture ; 
while  the  failure  to  detect  crepitus  might  easily  be  explained  by  the 
thickness  of  the  muscular  walls  at  this  point,  or  by  the  riding,  or  by 
other  displacements  of  the  broken  fragments. 

Chelius  speaks  of  a  peculiar  "  rustling,"  perceived  when  the  body  and 
ribs  are  moved  by  the  surgeon  or  by  the  patient  himself,  and  which 
is  different  from  the  sensation  produced  by  emphysema  or  fracture. 

The  treatment  ought  to  be  the  same  which  would  be  adopted  in 
case  the  rib  was  broken.  Eeplacement  of  the  dislocated  bone  must  be 
regarded  as  impossible ;  and  it  only  remains  that  we  insure  quiet  as 
far  as  possible  in  this  portion  of  the  chest,  and  combat  the  pain  and 
inflammation  by  suitable  remedies.     The  circular  bandage,  however 

'  Webster,  B.  Cooper's  ed.  of  Sir  Astley  Cooper,  Amer.  ed.,  p.  450. 


DISLOCATIONS    OF    THE    CARTILAGES    OF    THE    RIBS.      523 

recommended  ia  these  cases  by  Sir  Astley  Cooper,  could  only  be 
serviceable  in  dislocations  of  those  ribs  which  have  an  attachment  to 
the  sternum  ;  the  floating  ribs,  which  have  been  found  dislocated  quite 
as  often  as  either  of  the  others,  could  derive  no  support  from  circular 
pressure,  or  from  any  other  mechanical  contrivance. 

§  2.  Dislocations  of  the  Cartilages  of  the  Riiss  from  the  Sternum. 

The  cartilage  of  the  first  rib  has  no  proper  articulation  at  either 
extremity,  but  the  remaining  six  upper  ribs,  where  they  join  the 
sternum,  are  furnished  with  synovial  capsules.  In  old  age  these 
articulations  generally  disappear,  yet  not  always. 

Charles  Bell  observes:  "A  young  man  playing  the  dumb-bells  and 
throwing  his  arms  behind  him,  feels  something  give  way  on  the  chest; 
and  one  of  the  cartilages  of  the  ribs  has  started  and  stands  prominent. 
To  reduce  it,  we  make  the  patient  draw  a  full  inspiration,  and  with 
the  fingers  knead  the  projecting  cartilage  into  its  place.  We  apply  a 
compress  and  bandage,  but  the  luxation  is  with  difficulty  retained." 

Ravaton,  Manzotti,  and  Monteggia  have  each,  according  to  Mai- 
gaigne,  reported  one  example  of  traumatic  dislocation;  in  all  of  which 
the  cartilages  were  thrown  forwards  in  advance  of  the  sternum. 

When  treating  of  fracture  of  the  sternum,  I  have  related  one  case, 
which  has  come  under  my  own  observation,  of  dislocation  of  three  or 
four  cartilages  at  the  same  time. 

By  pressure  alone  they  have  generally  been  replaced,  the  cartilage 
resuming  its  position  suddenly  and  with  a  sound.  The  reduction 
may,  nevertheless,  be  facilitated  by  bending  the  trunk  backwards  or 
by  directing  the  patient  to  make  a  full  inspiration. 

To  maintain  the  reduction  has  been  found  more  difficult,  and  Sir 
Astley  directs  that  "a  long  piece  of  wetted  pasteboard  should  be 
placed  in  the  course  of  three  of  the  ribs  and  their  cartilages,  the 
injured  rib  being  in  the  centre;  this  dries  upon  the  chest,  takes  the 
exact  form  of  the  parts,  prevents  motion,  and  affords  the  same  support 
as  a  splint  upon  a  fractured  limb.  A  flannel  roller  is  to  be  applied 
over  this  splint,  and  a  system  of  depletion  pursued,  to  prevent  inflam- 
mation of  the  thoracic  viscera."  Instead  of  the  pasteboard,  we  might 
use  either  felt,  sole-leather,  or  gutta  percha. 

The  patients  spoken  of  by  Ravaton  and  Manzotti  were  both  cured 
in  about  one  month. 

Mr.  Bransby  Cooper  says  that  a  baker's  boy  applied  for  relief  at 
Guy's  Hospital,  who  was  the  subject  of  displacement  of  the  cartilages 
of  the  fifth  and  sixth  ribs  from  their  junction  with  the  sternum,  pro- 
duced partly  by  the  constant  action  of  the  pectoral  muscles  in  kneading 
bread,  but  principally  by  his  defective  constitution.  Mr.  Cooper  stated 
to  the  boy  the  necessity  of  changing  his  occupation,  and  advised  him 
to  go  into  the  country;  but  as  he  was  unable  to  do  so,  little  hope  was 
entertained  of  his  recovery.^ 

'  B.  Cooper's  ed.  of  Sir  Astley  Cooper,  &c.,  op.  cit.,  p.  447. 


524  DISLOCATIONS    OF    THE    CLAVICLE. 

§  3.  Dislocation  or  one  Cartilage  upon  Another. 

The  cartilages  on  the  sixth,  seventh,  and  eighth  ribs  are  furnished 
at  their  lower  borders  with  a  true  arthrodial  joint,  by  which  they 
articulate  with  the  corresponding  cartilages.  This  arrangement  some- 
times extends  to  the  fifth  and  ninth  ribs. 

A  displacement  of  -these  articulations  may  talce  place  when  one 
falls  upon  his  back,  striking  upon  some  projecting  body,  so  that  the 
chest  is  suddenly  thrown  forwards;  in  consequence  of  which  the 
upper  margin  of  the  lower  cartilage  is  depressed  and  entangled  be- 
hind the  lower  margin  of  the  upper.  The  inferior  cartilage  is,  there- 
fore, the  one  which  is  displaced  rather  than  the  superior,  although 
this  latter  being  made  prominent  by  the  pressure  of  the  other  from 
behind,  seems  alone  to  be  displaced.  Boyer,  Martin,  and  Malgaigne 
have  each  reported  one  example. 

It  is  probable  that  the  contraction  of  the  pectoral  and  abdominal 
muscles  has  a  chief  agency  in  the  production  of  these  dislocations,  and 
that  they  are  not  solely  or  directly  due  to  the  shock  of  the  accident. 

The  treatment  consists  in  pressing  firmly  upwards  and  backwards 
against  the  inferior  margin  of  the  upper,  or  overlapping  rib,  so  as  to 
disengage  it  from  the  lower,  when  by  its  own  elasticity  it  will  resume 
its  natural  position.  The  reduction  might  also  be  aided  by  a  full  in- 
spiration. 


CHAPTER   V. 

DISLOCATIONS  OF  THE  CLAVICLE. 

Of  46  dislocations  of  the  clavicle  observed  by  me,  9  belonged  to  the 
sternal  end  and  87  to  the  acromial.  Of  those  belonging  to  the  sternal 
end,  7  were  dislocations  Ibrwards,  forwards  and  upwards,  or  forwards 
and  downwards,  and  2  were  upwards.  I  have  never  met  with  a  dis- 
location backwards.  Of  the  acromial  dislocations,  the  whole  number 
were  dislocations  upwards,  or  upwards  and  outwards. 

§  1.  Dislocation  Forwards  at  the  Sternal  End. 

Causes. — This  accident  is  generally  caused  by  a  fall  upon  the  point 
of  the  shoulder,  in  consequence  of  which  the  sternal  end  of  the  cla- 
vicle is  driven  forcibly  inwards  and  forwards.  It  is  probable,  also, 
that  the  blow  which  produces  the  dislocation  is  received  rather  upon 
the  anterior  and  outer  face  than  exactly  upon  the  extremity  of  the 
shoulder.  A  sudden  eftbrt  of  the  muscles,  as  in  the  attempt  to 
balance  a  weight  upon  the  head,  or  to  throw  the  shoulders  backwards 
when  under  drill,  has  been  known  also  to  produce  this  dislocation. 
In  one  example  it  was  occasioned  by  placing  the  knee  against  the 
spine  and  drawing  the  shoulders  forcibly  back.     Various  other  acci- 


DISLOCATION    FORWAEDS    AT    THE    STERNAL    END.      525 


Fiij.  230. 


dents,  the  philosophy  of  whose  agency  is  not  so  easily  explained,  are 
said  to  have  produced  the  same  result ;  but  it  is  not  improbable  that 
in  many  of  these  cases  the  precise  manner  in  which  the  injury  was 
received  has  not  been  correctly  understood  or  reported. 

Mr.  Fergusson  has  once  seen  this  displacement  in  a  newly-born 
infant,  which  had  happened  during  birth.  It  could  be  replaced  with 
ease,  but  immediately  slipped  out  again  when  left  to  itself.  "  Nothing 
was  done;  a  new  joint  formed,  and  the  child  afterwards  possessed  as 
much  power  in  the  one  arm  as  in  the  other."^ 

Sym'ploms. — The  head  of  the  bone,  unless  the  person  is  exceedingly 
ftxt,  or  great  swelling  has  supervened,  can  be  distinctly  felt  and  seen 
in  front  of  the  sternum;  the  corresponding  shoulder  falls  a  little  back; 
the  head  inclines  also  sometimes  to  the  same  side;  the  movements  of 
the  arm  are  embarrassed,  and  accompanied  almost  always  with  an  acute 
pain  at  the  point  of  dislocation.  The  clavicular  portion  of  the  sterno- 
cleido-mastoid  muscle  presents  an  unusually  sharp  and  projecting 
outline,  and  a  careful  measurement  indicates,  if  the  dislocation  is 
complete,  a  sensible  approach  to  the 
acromion  process  toward  the  centre 
of  the  sternum.  If  now  the  surgeon 
places  his  knee  against  the  spine,  and 
draws  the  shoulders  back,  the  pro- 
jection of  the  clavicle  in  front  dimin- 
ishes or  disappears ;  if  he  carries  the 
shoulder  up,  it  descends ;  and  if  he 
depresses  the  shoulder,  it  ascends. 

The  simplicity  and  uniformity  of 
the  symptoms  which  usually  charac- 
terize this  accident  will  generally  pre- 
vent the  possibility  of  a  mistake  ;  but 
Pinel  mentions  the  case  of  a  man  who 
having  presented  himself  at  one  of  the 
hospitals  of  Paris,  suffering  under  this 
dislocation,  the  surgeon-in-chief  thought  it  a  tumor  of  the  bone,  and 
advised  the  application  of  a  plaster ;  and,  on  the  other  hand,  a  patient 
presented  himself  to  Velpeau,  who  had  been  treated  for  a  dislocation, 
when  the  bone  was  only  expanded  by  disease. 

I  have  myself  also  seen  a  fracture  so  near  the  sternal  end  of  the 
bone  as  not  to  be  easily  distinguished  from  a  dislocation. 

Pathology. — In  complete  anterior  luxation  of  the  clavicle,  the  cap- 
sular ligament  suffers  a  complete  disruption,  and  also  the  anterior 
with  the  posterior  sterno-clavicular  ligaments.  The  rhomboid  and 
interarticular  ligaments  suffer  more  or  less,  according  to  the  extent  of 
the  displacement.  The  interarticular  cartilage  may  retain  its  attach- 
ment to  the  sternum,  or  it  may  be  carried  forwards  with  the  clavicle. 
The  head  of  the  bone  lies  immediately  underneath  the  skin  and  in 
front  of  the  sternum;  and  generally  it  is  found  to  have  descended  a 
little  upon  its  anterior  surface.     Richerand  saw  a  case  in  which  the 


Dislocation  of  the  sternal  end  forwards. 


>  Fergusson,  System  ot  Practical  Surgery,  Amer.  ed.,  1853,  p.  203. 


526  DISLOCATIONS    OF    THE    CLAVICLE. 

sternal  extremity  of  the  bone  was  placed  three  inches  below  the  top 
of  the  sternum. 

Wherever  the  bone  lies  it  carries  with  it  the  clavicular  fasciculus 
of  the  sterno-cleido-mastoid  muscle. 

Treatment. — Not  one  of  the  seven  forward  dislocations  of  the 
clavicle  at  the  sternal  end  seen  by  me  has  been  completely  reduced, 
or  if  reduced  they  have  not  been  retained  in  place.  In  the  following 
example  the  reduction,  although  faithfully  attempted,  was  never 
accomplished. 

Mr.  H.,  of  Buffalo,  set.  45,  was  thrown  by  a  horse,  suffering  at  the 
same  moment  a  fracture  of  the  leg  and  a  forward  dislocation  of  the 
left  clavicle  at  its  sternal  end. 

Prof  James  P.  White,  with  whom  I  was  in  consultation,  made 
several  attempts  to  reduce  the  dislocation  by  placing  the  knee  against 
the  spine  and  pulling  the  shoulder  forcibly  back,  and  the  same  efforts 
were  repeated  by  myself,  but  without  accomplishing  the  reduction. 
We  also  endeavored  to  reduce  it  by  pressing  directly  upon  the  pro- 
jecting bone  and  by  placing  a  pad  in  the  axilla,  using  the  arm  as  a 
lever  as  recommended  by  Desault,  and  with  no  better  result. 

This  patient  was  tolerably  muscular,  but  while  we  were  manipu- 
lating he  was  very  much  enfeebled  by  the  shock  of  the  accident. 

Finding  that  it  was  impossible  to  reduce  the  dislocation  by  any 
moderate  amount  of  force,  and  believing  that  if  we  were  to  succeed 
we  could  not  retain  the  bone  in  place,  and  the  more  especially  because 
his  left  side  was  so  much  bruised  that  he  could  not  bear  an  axillary 
pad  or  bandages  of  any  kind,  we  desisted  from  any  further  attempts. 

Two  years  later  I  examined  the  shoulder  and  found  the  clavicle 
still  unreduced,  and  its  position  unchanged.  When  he  carries  the 
shoulder  forwards  or  backwards,  there  is  a  corresponding  motion  at 
the  sternal  end  of  the  clavicle.  The  arm  is  not  quite  as  strong  as  the 
other,  and  its  freedom  of  motion  is  slightly  impaired. 

I  have  also  in  my  museum  the  cast  of  a  case  of  complete  forward 
dislocation  at  this  point;  which  accident  occurred  io  a  lad  twelve 
years  old,  who  had  fallen  into  a  cellar  on  the  20th  of  Aug.  1856.  The 
late  Dr.  Lewis  and  Dr.  Dayton,  both  excellent  surgeons,  had  examined 
the  arm,  and  dressings  had  been  applied  with  a  view  to  maintain  the 
reduction;  but  on  the  fifth  day  after  -the  accident  I  found  the  bone 
displaced;   nor  do  I  think  reduction  was  ever  afterwards  maintained. 

A  lad  was  brought  into  the  Buffalo  Hospital  of  the  Sisters  of 
Charity,  with  a  dislocation  of  the  same  character,  on  the  25th  of  Sept. 
1858,  who  had  been  run  over  by  a  wagon  on  the  same  day.  Dr.  E. 
P.  Smith,  one  of  the  surgeons  of  the  hospital,  attempted  faithfully  to 
reduce  it,  but  Avas  unable  to  do  so.  Five  days  after,  I  found  the  bone 
out  and  quite  movable.  All  apparatus  having  been  removed,  we  laid 
him  upon  his  back  in  bed,  and  kept  him  in  this  position  three  weeks. 
He  was  then  dismissed  with  no  change  in  the  appearance  of  the  bone, 
but  he  could  move  the  arm  as  well  as  before  the  accident. 

Other  surgeons  have  not  met  with,  or  at  least  they  have  not  men- 
tioned, any  cases  in  which  the  reduction  of  this  dislocation  was  attended 
with  difficulty,  nor  am  I  prepared  to  explain  the  difficulty  which  was 


Fi?.  231. 


DISLOCATION    FORTTARDS    AT    THE    STERNAL    EXD.      527 

experienced  in  my  own  (Mr.  H.),  and  in  Dr.  E.  P.  Smith's  case.  Pro- 
bably they  ought  to  be  regarded  as  exceptions  to  the  general  rule. 
But  most  surgeons  have  testified  to  the  difficulty  of  retaining  it  in 
place  when  reduction  has  been  fairly  accomplished,  Chelius  says 
"there  commonly  remains  more  or  less  deformity,"  and  Malgaigne 
says  that  "  it  is  difficult  and  rare  to  cure  it  without  deformity." 

Nevertheless,  Desault(or,  rather,  his  pupil  Bichat,  who  has  published 
his  lectures),  who  always  speaks  very  confidently  of  his  ability  to  retain 
either  broken  or  dislocated  bones 
in  their  places,  says  that  he 
"  almost  always  obtained  com- 
plete success"  with  his  appara- 
tus. It  is  remarkable,  however, 
that  of  the  three  examples  fur- 
nished by  Bichat  to  confirm  this 
statement,  all  of  which  were 
treated  by  Desault  himself,  one 
recovered  after  a  long  time  with 
a  "  very  perceptible  protuber- 
ance in  front  of  the  sternum," 
one  with  a  "  very  slight  protu- 
berance," and  in  the  other  the 
"swelling  was  almost  gone"  on 
the  twentieth  day,  and  we  are 
left  in  doubt  as  to  whether  the 
reduction  was  any  more  com- 
plete than  in  either  of  the  other 
cases.'  Richerand  and  Guersant 
succeeded  no  better  with  De- 
sault's  dressings.^ 

Other    surgeons   have    made 
similar    claims    for    their   own 
forms  of  apparatus,  but  experience  still  continues  to  show  that  a  com- 
plete retention  of  the  dislocated  bone  is  seldom  to  be  expected. 

Sir  Astley  recommends  an  apparatus,  the  construction  and  appli- 
cation of  which  are  illustrated  by  the  accompanying  sketch,  the  object 
of  which  is  to  draw  the  shoulders  back,  and  at  the  same  time,  by  the 
aid  of  two  pads  or  cushions  in  the  axillse,  to  carry  the  shoulders  out- 
wards. The  dressing  is  then  completed  by  placing  the  arm  in  a  sling. 
He  advises,  however,  that  in  some  way  direct  pressure  should  be  made 
upon  the  projecting  point  of  bone. 

Yelpeau  objects  to  any  plan  which  will  draw  the  shoulders  back ; 
but,  on  the  contrary,  he  thinks  that  the  shoulders  should  be  kept 
slightly  forwards,  so  as  to  diminish  the  tendency  of  the  sternal  end  of 
the  clavicle  to  escape  in  this  direction. 

Until  further  observations  have  determined  the  relative  value  of 
these  and  of  many  other  processes,  it  will  be  well  to  adopt  no  fixed 


Sir  Aatley  Cooper's  apparatus  for  dislocated  clavicle. 


1  Desault  on  Fractures  and  Dislocations,  by  Xav.  Bicliat,  Philada.  ed.,  1805,  p.  53. 

2  Malgaigne,  op.  cit.,  torn.  ii.  p.  417. 


528  DISLOCATIONS    OF    THE    CLAVICLE. 

rule  of  action ;  but,  having  reduced  the  bone  by  either  placing  the 
knee  upon  the  spine  and  drawing  the  shoulders  back,  or  by  making 
use  of  the  humerus  as  a  lever,  we  recommend  that  the  surgeon  shall 
seek  to  maintain  it  in  place  by  such  means  as  the  experiment  shall 
prove  are  most  successful.  Among  these  means,  direct  pressure  upon 
the  sternal  end  of  the  clavicle,  the  sling,  and  perfect  quietude  of  the 
muscles  of  the  arm  through  the  aid  of  bandages,  are  no  doubt  of  the 
greatest  importance,  and  can  seldom  be  omitted.  If  then  we  find  that 
a  position  of  the  shoulders  more  or  less  forwards  or  backwards  best 
maintains  the  apposition,  this  position,  whatever  it  is,  ought  to  be 
continued. 

In  order  to  be  successful,  sufficient  time  must  elapse  for  the  torn 
ligaments  to  become  firmly  reunited,  during  which  the  reduction  must 
be  constant;  since  every  time  the  bone  escapes,  the  whole  work  of 
repair  has  to  be  recommenced  as  from  the  beginning.  To  this  end  at 
least  four  or  six  weeks  are  necessary,  and  sometimes  the  period  must 
be  lengthened  far  beyond  these  limits ;  so  that  it  may  often  become  a 
grave  point  of  inquiry  whether  the  long  confinement  of  the  limb  will 
not  entail  more  serious  consequences  than  have  ever  been  known  to 
arise  from  leaving  the  bone  displaced.  In  no  case  seen  by  me  has 
the  function  of  the  arm  been  seriously  impaired  by  the  displacement. 

§  2.  Dislocation  or  the  Sternal  End  op  the  Clavicle  Upwards. 

Malgaigne  has  collected  four  undoubted  examples  of  this  dislocation, 
and  I  have  been  unable  to  find  a  report  of  any  other  except  the  very 
extraordinary  case  described  by  l)r.  Eochester,  at  the  September 
meeting  of  the  Buffalo  Medical  Association,  and  which  case,  through 
the  courtesy  of  Dr.  Eochester,  I  was  permitted  to  see  several  times.^ 

Jerry  McAuliffe,  ast.  44,  on  the  28th  of  August,  1858,  while  seated 
upon  a  load  of  wood,  was  caught  under  the  bar  of  a  gateway  and 
violently  crushed,  the  right  shoulder  being  forced  downwards  and  a 
little  backwards.  Dr.  Eochester  saw  him  very  soon  after  the  accident. 
On  examination,  it  was  found  that  the  sternal  extremity  of  the  right 
clavicle  was  thrown  upwards  so  far  as  to  rest  upon  the  front  of  the 
thyroid  cartilage,  occasioning  considerable  pain,  difficulty  of  respira- 
tion, and  loss  of  speech.  Eeduction  was  easily  effected,  and  a  retentive 
apparatus  was  immediately  applied,  consisting  of  a  gutta-percha  splint, 
moulded  to  the  clavicle  and  ribs,  and  retained  in  place  with  adhesive 
plaster.  Suitable  bandages,  a  sling,  &c.,  were  also  employed  to  main- 
tain complete  rest. 

Notwithstanding  all  the  care  employed,  the  bone  again  became 
displaced,  and  when,  near  four  months  after  the  accident,  this  man 
came  before  the  class  of  medical  students  at  the  Hospital  of  the  Sisters 
of  Charity,  we  found  the  sternal  end  of  the  clavicle  carried  upwards 
half  an  inch,  and  across  toward  the  opposite  side  also  about  half  an 
inch,  and  projecting  somewhat  in  front.  It  was  fixed  in  this  position 
by  ligaments  which  allowed  it  to  move  much  more  freely  than  natural, 

'  Rochester,  Buffalo  Med.  Journ.,  vol.  xiv.  p.  262. 


OF    THE    STERNAL    END    OF    CLAVICLE    UPWAEDS.       529 

but  which  would  not  permit  any  great  displacement.  The  correspond- 
ing shoulder  was  slightly  depressed,  McAuliffe  said  that  he  felt  no 
inconvenience  or  abatement  of  strength  in  the  arm  except  when  he 
attempted  to  lift  weights  above  his  head. 

In  April,  1870, 1  met  with  a  similar  case  in  a  woman  fifty  years  of 
age,  which  had  been  caused  by  a  fall  upon  the  shoulders  nine  weeks 
before,  and  which  had  been  overlooked  by  her  surgeon  in  the  first 
instance.  When  seen  by  me  it  was  immovably  fixed  in  its  new 
position. 

The  accident  seems  to  have  been  produced  in  all  the  cases,  so  far 
as  can  be  ascertained,  by  a  force  operating  upon  the  end  and  top  of 
the  shoulder ;  in  consequence  of  which  the  head  of  the  clavicle  is 
pushed  and  at  the  same  time  lifted,  as  it  were,  from  its  socket,  tearing 
not  only  its  capsule  with  the  ligaments  which  immediately  invest  the 
capsule,  but  also  in  some  instances  the  costo-clavicular  ligament  with 
some  fibres  of  the  subclavian  muscle.  The  sternal  end  of  tlie  clavicle 
is  found  riding  upon  the  top  of  the  sternum,  its  head  being  placed 
between  the  sternal  fasciculus  of  the  sterno-cleido-mastoid  muscle 
on  the  one  hand,  and  the  sterno-hyoid  muscle  on  the  other.  In 
one  of  the  cases  seen  by  Malgaigne  the  head  had  traversed  in  this 
direction  completely  the  intra-clavicular  space,  and  lay  behind  the 
sternal  portion  of  the  opposite  sterno-cleido-mastoid  muscle. 

The  symptoms  are,  a  depression  of  the  shoulder,  with  an  elevation 
of  the  sternal  end  of  the  clavicle  so  as  to  increase  sensibly  the  space 
between  it  and  the  first  rib.  The  clavicle  also  encroaches  more  or 
less  upon  the  supra-sternal  fossa,  occasioning  a  corresponding  dimi- 
nution of  the  space  between  the  end  of  the  shoulder  and  the  centre  of 
the  sternum.  The  sternal  portion  of  one  or  both  of  the  sterno-cleido- 
mastoid  muscles  may  also  be  seen  raised  and  rendered  tense  by  the 
pressure  of  the  head  of  the  bone  from  behind. 

Fig.  233. 


Dislocatiou  of  the  sternal  ead  of  the  clavicle  upwards. 

Reduction  has  been  found  easy,  but  Malgaigne  thinks  a  perfect 
retention  impossible,  at  least  it  does  not  seem  to  have  been  accom- 
plished in  any  of  the  cases  reported.  In  no  case  did  the  displace- 
ment seriously  impair  the  functions  of  the  arm. 


530  DISLOCATIONS    OF    THE    CLAVICLE. 

The  same  apparatus  to  which  we  shall  give  the  preference  in  cases 
of  dislocation  upwards  of  the  acromial  end  of  the  clavicle,  at  least  with 
only  such  slight  modifications  as  the  peculiarities  of  the  case  will 
naturally  suggest,  will  be  suitable  for  this  accident.  The  shoulder 
must  be  lifted  by  a  sling,  while  the  sternal  end  of  the  clavicle  is 
pressed  downwards  by  a  pad  and  bandages ;  and  all  the  muscles  of  the 
arm  and  chest,  so  far  as  is  consistent  with  respiration  and  comfort, 
must  be  maintained  in  a  state  of  perfect  rest  until  the  ligaments  have 
become  reunited. 

§  3.  Dislocations  op  the  Sternal  End  of  the  Clavicle  Backwards. 

The  first  case  upon  record  of  this  kind  of  accident,  caused  by 
violence,  was  published  by  Pellieux  in  183-i,  in  the  Revue  Medicale; 
until  which  time  its  existence  had  been  generally  denied.  In  the 
London  and  Edinburgh  Journal  of  Medical  Science  for  October,  1811, 
Several  cases  are  mentioned. 

Two  forms  of  the  accident  have  been  described,  one  in  which  the 
bead  of  the  clavicle  is  driven  backwards  and  a  little  downwards ;  and 
another  in  which  it  is  displaced  directly  backwards,  or  backwards  and 
a  little  upwards.  In  both  of  these  classes,  the  end  of  the  bone  falls 
inwards  toward  the  opposite  clavicle,  and  occupies  a  space  in  the 
cellular  tissue  back  of  the  sterno-hyoid  and  sterno-thyroid  muscles, 
and  in  front  of  the  oesophagus ;  the  trachea,  if  reached  at  all,  being 
probably  thrust  to  the  opposite  side. 

The  examples  in  which  it  has  been  found  below  the  top  of  the 
sternum  are  much  the  most  numerous;  indeed,  it  is  probable  that  the 
other  form  is  only  a  secondary  displacement,  occasioned  by  the  action 
of  the  fibres  of  the  sterno-cleido-mastoid  muscle. 

Causes. — Of  the  eleven  examples  mentioned  by  Malgaigne,  four 
were  occasioned  by  direct  blows,  and  most  of  the  remainder  by  crush- 
ing accidents,  as  by  powerful  lateral  compression  of  the  shoulders. 

One  of  the  cases  produced  by  a  direct  blow  was  accompanied  with 
an  external  wound,  and  is  the  only  instance  of  a  compound  dislocation 
of  this  kind  upon  record.  The  man  was  admitted  into  St.  Thomas's 
Hospital  in  Sept.  1835,  and,  according  to  his  own  account,  the  sharp 
end  of  a  pickaxe  had  been  driven  through  the  flesh  against  the  bone. 
The  sternal  end  of  the  clavicle  was  found  to  be  displaced  backward, 
and  with  the  finger  thrust  into  the  wound  on  the  front  of  the  chest,  it 
could  be  distinctly  felt  resting  upon  the  side  and  front  of  the  trachea, 
where  it  interfered  somewhat  with  respiration  and  deglutition.  He 
had  a  great  desire  to  cough,  with  a  sensation  of  pressure  on  his  wind- 
pipe, which  was  greatly  increased  when  his  head  was  thrown  back. 
There  was  also  a  slight  emphysema  in  the  region  below  the  collar-bone 
and  over  the  top  of  the  sternum.  The  shoulder  having  been  brought 
back  with  straps  attached  to  a  back-board,  the  bone  readily  resumed 
its  place.  The  elbow  was  then  brought  forwards  and  bound  to  the 
side,  and  the  wound  being  closed  with  adhesive  plaster,  he  was  put  to 
bed  with  the  shoulders  much  raised.  No  unfavorable  symptoms  fol- 
lowed, and  in  three  weeks  he  left  his  bed.     Three  weeks  later  he  left 


OF    THE    STEENAL    END    OF    CLAVICLE    BACKWARDS.       531 

the  liospital  with  the  sternal  end  of  the  bone  still  falling  a  little  back- 
wards, and  rather  more  movable  than  natural.* 

The  following  example,  related  bj  Morel -La  valine,  will  illustrate 
that  class  in  which  the  dislocation  results  from  an  indirect  blow,  or 
from  a  crushing  accident. 

Lemoine,  seventeen  years  old,  had  his  right  shoulder  violently- 
pressed  against  a  wall  by  a  carriage.  He  experienced  at  the  moment 
some  pain  at  the  bottom  of  his  neck,  and  a  great  sensation  of  suffocation, 
which  lasted  for  more  than  a  quarter  of  an  hour.  The  dyspnoea  gradu- 
ally subsided,  but  the  motion  of  the  right  arm  not  returning,  he,  on 
the  eighth  day  after  the  accident,  entered  La  Charit^.  On  examination, 
the  two  shoulders  were  found  to  be  on  the  same  level,  but  the  right 
one  was  nearer  the  median  line.  The  internal  extremity  of  the  clavicle 
was  half  concealed  behind  the  sternum.  On  depressing  the  shoulder, 
the  inner  end  of  the  clavicle  arose  and  disengaged  itself  from  behind 
the  sternum ;  but  reduction  was  effected  by  elevating  the  shoulder, 
while  at  the  same  time  it  was  carried  outwards  and  backwards.  De- 
sault's  bandage  was  then  applied,  but  as  it  became  loosened,  Velpeau's 
was  substituted,  which  kept  the  bone  completely  in  position  until  the 
eighteenth  day,  when  the  patient  was  lost  sight  of.^ 

Symptoms. — The  most  constant  symptoms  are,  the  absence  of  the 
head  of  the  bone  from  its  socket,  and  its  complete  or  partial  disap- 
pearance behind  the  sternum,  an  approach  of  the  corresponding  shoul- 
der to  the  median  line,  an  inclination  of  the  head  to  the  opposite  side, 
elevation  of  the  shoulder,  pain  at  the  bottom  of  the  neck,  impairment 
of  the  motions  of  the  arm,  sometimes  difficulty  in  respiration  and  in 
deglutition,  partial  arrest  in  the  circulation  of  the  arm  from  pressure 
upon  the  subclavian  artery,  and  a  slight  projection  of  the  acromial  end 
of  the  clavicle,  noticed  twice  by  Morel-Lavall^e. 

It  has  not  generally  been  found  difhcult  to  reduce  this  dislocation, 
nor,  when  reduced,  is  it  so  liable  to  again  become  displaced  as  are  the 
dislocations  forwards  ;  yet  in  only  a  few  instances  has  the  restoration 
been  so  complete  as  not  to  leave  some  deformity. 

In  order  to  the  reduction,  the  shoulder  must  be  carried  generally 
upwards,  outwards,  and  backwards,  and  it  may  then  be  best  main- 
tained in  position  by  laying  the  patient  on  his  back  upon  an  elevated 
cushion,  as  practised  by  Tyrrell  in  the  case  related  by  South.  To  this 
may  be  added  such  other  measures,  differing  but  little  from  those  era- 
ployed  in  other  dislocations  of  the  clavicle,  as  are  necessary  to  insure 
complete  rest  to  the  muscles.  Of  course,  no  pads  or  bands  across  the 
clavicle  can  be  of  any  service  in  this  case*. 

As  in  the  other  cases  of  dislocation  at  this  point,  the  patients  have 
generally  recovered  nearly  the  full  use  of  their  arms,  even  in  one  or 
two  instances  in  which  the  reduction  has  never  been  accomplished. 

'  Soiith,  note  to  Clielius's  Surgery,  Amer.  ed.,  vol.  ii.  p.  218. 

2  Morel-Lavallee,  Amer.  Journ.  Med.  Sci.,  vol.  xxix.  p.  229, 1842;  fromGaz.  Mod. 


532  DISLOCATIONS    OF    THE    CLAVICLE. 

§  4.  Dislocation  op  the  Acromial  End  of  the  Clavicle  Upwards, 

Of  all  the  dislocations  of  the  clavicle,  this  form  is  most  frequent. 
I  have  met  with  it  either  as  a  partial  or  complete  luxation  thirty-seven 
times.  The  youngest  subject  was  seven  years  of  age,  and  the  oldest 
sixty-three.     All  but  one  were  males. 

Causes. — It  is  produced  generally  by  a  fall  upon  the  extremity  of 
the  shoulder.  Twice  the  blow  has  been  received  rather  upon  the 
back  than  upon  the  extremity,  and  once  it  was  occasioned  by  the  fall 
of  a  board  directly  upon  the  top  of  the  shoulder,  and  once  by  a  bolt 
thrust  directly  up  from  under  the  clavicle. 

Symptoms. — When  the  dislocation  is  complete,  the  clavicle  not  only 
is  lifted  from  its  articular  facet  to  the  extent  of  the  breadth  of  the 
bone,  but  it  is  pushed  more  or  less  outwards  over  the  top  of  the  acro- 
mion process  ;  generally  less  than  half  an  inch,  but  I  have  once  seen  it 
riding  the  process  to  the  extent  of  three-quarters  of  an  inch.  In  this 
last  example,  the  case  of  James  Moran,  a  strong,  healthy  laboring  man, 
the  clavicle  was  easily  reduced,  and  it  always  went  into  place  with  a 
sensible  click ;  but  although  every  possible  care  was  taken  to  retain 
it  in  place  by  bandages,  compresses,  an  axillary  pad,  and  a  sling,  yet 
it  was  not  accomplished,  and  on  the  third  day  he  removed  all  the 
dressings,  and  refused  to  have  them  reapplied. 

I  have  usually  found  the  shoulder  slightly  depressed ;  and  in  one 
instance  where  it  is  probable  the  deltoid  muscle  had  suffered  some  in- 
jury, the  elbow  hung  awa}'  from  the  body,  and  any  attempts  to  lay  it 
against  the  side  produced  an  acute  pain  in  the  shoulder.^  It  has  been 
noticed  also,  in  most  cases,  that  the  clavicular  portion  of  the  trapezius 
muscle  appeared  lifted  and  tense,  especially  when  the  neck  was  straight. 

Inability  to  raise  the  arm  to  a  right  angle  with  the  body  is  a  general 
but  not  constant  symptom.  In  two  instances,  where  the  displacement 
was  only  moderate,  the  patients  were  at  first  and  for  some  time  after- 
wards unable  to  lift  the  arm  in  any  degree  from  the  side.  In  one 
example,  a  lady  sixty  years  of  age  had  fallen  upon  her  shoulder  and 
produced  a  dislocation  upwards,  but  she  had  not  consulted  a  surgeon 
until  she  called  upon  me,  five  months  after  the  accident.  The  clavicle 
was  then  raised  from  its  socket  about  half  an  inch,  but  it  could  be 
easily  pressed  back  to  its  place,  the  reduction  being  attended  with  a 
grating  sensation,  a  circumstance  which  I  have  not  noticed  in  any  other 
instance.  She  was  not  even  then  able  to  raise  her  arm  to  her  head, 
nor  had  she  been  able  to  do  so  since  the  accident  occurred. 

In  all  the  motions  of  the  arm  and  shoulder,  the  clavicle  is  seen  to 
move  more  freely  than  natural  immediately  under  the  skin,  and  these 
motions  are  usually  attended  with  some  pain  at  the  point  of  dislocation. 

This  accident  has  been  sometimes  mistaken  for  a  dislocation  of  the 
humerus,  but  unless  the  shoulder  is  already  greatly  swollen,  the  error 
is  not  likely  to  happen.  If  the  point  of  the  acromion  process  can  be 
made  out,  it  will  be  easy  to  determine,  by  sliding  the  finger  along  its 
spine,  whether  the  clavicle  is  displaced  or  not,  and  by  these  means  to 

'  Report  on  Dislocations,  by  the  author.  Transac.  of  New  York  State  Med.  Soc., 
1855,  p.  19. 


OF    THE    ACROMIAL    END    OF    CLAVICLE    UPWAEDS. 


533 


Fi2;.  233. 


Dislocation  of  the  acromial  end  of  thee  lavi- 
cle  upwards. 


settle  the  question  of  its  complicity  in  the  accident.  The  question  as 
to  whether  the  shoulder  is  dislocated  or  not  may  be  more  difficult  of 
solution,  as  we  shall  hereafter  have  occasion  again  to  observe. 

Pathology. —  Generally  there  exists  simply  a  rupture  of  the  liga- 
ments immediately  investing  the  joint,  so  that  the  clavicle  rises  from 
its  socket  only  about  half  an  inch,  more  or  less,  according  to  its  dia- 
meter, and  is  carried  outwards  just 
sufficiently  far  to  allow  it  to  rest  upon 
the  upper  margin  of  the  acromial  ar- 
ticulation. In  at  least  twenty-eight 
of  the  cases  seen  by  me  this  has  been 
the  position  of  the  acromial  end  of 
the  clavicle,  and  for  its  complete  re- 
duction nothing  more  has  been  re- 
quired than  to  press  with  moderate 
force  upon  the  upper  and  outer  end 
of  the  bone. 

In  five  cases  I  have  found  the 
bone  not  only  thus  lifted  in  its  socket, 
but  also  driven  over  upon  the  acro- 
mion process  from  half  to  three- 
quarters  of  an  inch;  and  in  one  in- 
stance, that  of  a  gentleman,  Mr.  B., 
who  was  injured  in  a  railroad  acci- 
dent, the  acromial  end  of  the  clavicle  was  displaced  outwards  half  an 
inch  and  backwards  three-quarters  of  an  inch,  while  the  sternal  end 
also  was  considerably  lifted  in  its  socket  and  slightly  sent  inwards. 
The  shoulder  fell  forwards  and  the  coracoid  process  was  one  inch 
nearer  the  sternum  than  the  same  process  upon  the  opposite  side. 
In  such  cases  more  or  less  of  the  fibres  of  the  coraco-clavicular  liga- 
ment must  have  suffered  a  disruption  ;  indeed,  without  a  rupture  of 
its  external  fasciculus,  which  anatomists 
have  called  the  trapezoid  ligament,  such 
a  dislocation  cannot  take  place. 

Prognosis. — It  is  impossible  for  me  to 
say  what  has  been  the  precise  result  in  all 
the  cases  which  I  have  seen,  but  my  notes 
furnish  only  two  cases  of  perfect  retention 
after  a  complete  dislocation  at  this  point. 
One  of  these,  David  Thomas,  aged  about 
twenty-five  years,  fell  sideways  upon  the 
ground,  striking  upon  the  extremity,  and, 
as  he  thinks,  a  little  upon  the  top  of  the 
shoulder.  I  found  the  clavicle  dislocated 
upwards  and  outwards,  so  that  it  over- 
lapped the  acromion  process  half  an  inch. 
It  was  easily  replaced,  and  having  applied 
my  own  apparatus  for  broken  collar-bones, 
with  the  addition  of  a  band   across  the 

TIT  1  1  .1  11  -I  Dislocation  of  the  aci'omial  end  of 

shoulder  and    under   the  elbow    to  keep    the  cuvicie  upwards  aaa  .mnvards. 


Fi!?.  234. 


534  DISLOCATIONS    OP    THE    CLAVICLE. 

the  clavicle  down,  I  found  that  I  had  succeeded  in  retaining  the  bone 
in  place.  This  dressing  was  continued  until  the  forty-second  day, 
when,  on  being  removed,  the  clavicle  was  seen  to  be  closely  confined 
upon  its  articulation ;  and  after  a  lapse  of  two  years  it  still  retains  its 
position  so  completely  that  no  diSerence  can  be  detected  between  the 
opposite  articulations. 

In  the  case  of  Moran,  already  mentioned,  whose  clavicle  overlapped 
the  acromion  process  three-quarters  of  an  inch,  and  who  threw  off  the 
dressings  at  the  end  of  three  days,  the  same  degree  of  displacement 
existed  at  the  end  of  two  years;  the  scapular  end  of  the  clavicle 
moving  freely  in  every  direction  under  the  skin  according  as  the  arm 
was  moved.  In  lifting,  he  says,  the  strength  of  his  arm  is  undimin- 
ished until  he  raises  the  weight  nearly  to  a  level  with  his  shoulders, 
and  from  this  point  upwards  he  can  lift  but  little.  For  a  laboring 
man  it  amounts  to  a  serious  maiming.  I  have  seen  the  same  loss  of 
power  in  the  arm  to  raise  bodies  above  the  head  in  at  least  two  or 
three  of  the  examples  of  less  complete  luxation,  continuing  after  the 
lapse  of  several  years ;  but  in  the  majority  of  cases,  although  the 
bone  does  not  remain  reduced,  the  patients  have  recovered  eventually 
the  complete  use  of  the  arm  in  whatever  position  it  may  be  placed. 

The  case  to  which  I  have  already  referred  as  having  been  caused  by 
a  bolt  thrust  upwards  under  the  clavicle,  will  furnish  the  best  illustra- 
tion of  this  general  principle.  James  O'Brien,  1st  U.  S.  Artillery, 
was  injured  in  September,  1862,  by  being  run  over  by  a  horse-car. 
A  bolt,  three-quarters  of  an  inch  in  diameter,  was  driven  through 
the  skin  on  the  anterior  margin  of  the  left  axilla,  breaking  the  first 
rib,  severing  the  coraco-clavicular  ligam.ents,  and  forcing  the  clavicle 
upwards  from  its  socket.  No  attempt  at  reduction  was  ever  made. 
When  seen  by  me  one  year  after  the  accident,  the  outer  end  of  the 
clavicle  was  lifted  directly  up  two  inches  from  the  acromion  process, 
to  which  it  was  united  only  by  a  long  and  slender  ligament.  He  was 
not  conscious  of  any  loss  of  power  or  limitation  of  motion  in  the 
injured  arm.  At  my  request,  my  son,  then  in  the  U.  S.  service,  insti- 
tuted a  series  of  experiments  to  test  the  relative  strength  of  the  two 
arms,  and  with  the  following  result:  First  with  the  right  arm,  and 
then  with  the  left,  he  lilted  from  the  ground  fifty-six  pounds  and  three 
ounces,  and  sustained  this  weight  above  his  head  thirty  seconds,  with  his 
arms  fully  extended.  With  his  right  arm  extended  at  full  length,  at 
right  angles  with  his  body,  he  sustained  twenty-five  pounds  for  fifteen 
seconds.  With  the  left  arm  he  sustained  the  same  weight,  in  the  same 
position,  seventeen  seconds.' 

Treatment. — When  the  bone  simply  rises  upon  its  socket,  the  re- 
duction is  always  easily  accomplished  by  pressing  firmly  upon  its 
extremity  with  the  fingers ;  but  if;  at  the  same  time,  it  has  been  car- 
ried outwards,  or  outwards  and  Isackwards,  the  reduction  is  only 
accomplished  by  pulling  the  shoulders  backwards,  or  by  placing  a 
pad  in  the  axilla,  using  the  arm  as  a  lever,  or  by  lifting  the  arm  by 
the  elbow  and  at  the  same  time  pressing  the  clavicle  down ;  and  it 

'  Am.  Med.  Times,  Oct.  24,  1863. 


OF    THE    ACROMIAL    END    OF    CLAVICLE    UPWARDS.      535 

will  sometimes  require  the  application  of  all  or  several  of  these  pro- 
cedures at  the  same  moment.  In  some  cases  the  complete  reduction 
has  only  been  effected  when  the  patient  has  been  brought  under  the 
influence  of  an  anesthetic. 

As  to  the  maintenance  of  the  bone  in  its  socket  for  a  length  of  time 
sufficient  to  insure  a  firm  union  of  the  broken  tissues,  this  will  be 
found  always  more  difficult,  and,  in  a  great  majority  of  cases,  abso- 
lutely impossible.  Nearly  all  surgeons  who  have  written  upon  this 
subject  have  made  the  same  observation ;  and  if  occasionally  a  new 
apparatus  in  the  hands  of  a  clever  surgeon  has  seemed  to  promise 
better  results,  the  same  apparatus  in  the  hands  of  other  equally  clever 
surgeons,  and  under  circumstances  equally  favorable,  has  been  found 
almost  constantly  to  fail ;  and  we  have  been  compelled  again  to  exer- 
cise anew  our  ingenuity,  and  to  seek  for  new  resources,  or  to  abandon 
the  effort  in  despair. 

Dr.  Folts,  of  Boston,  believed  that  he  had  found  in  Bartlett's  appa- 
ratus for  broken  clavicles,  modified  by  the  application  of  a  shoulder- 
strap,  the  infallible  remedy  for  this  one  of  the  many  sad  defects  in 
our  art.  The  most  important  part  of  this  dressing,  according  to  Dr. 
Folts,  is  the  compress  placed  upon  the  upper  and  outer  end  of  the 
clavicle,  and  the  bandage  or  strap  passed  over  the  compress  and  under 
the  point  of  the  elbow  to  maintain  it  in  position.^ 

Dr.  Folts  is  no  doubt  correct  in  regarding  this  strap  as  an  impor- 
tant if  not  the  essential  part  of  the  apparatus;  and  it  is  surprising 
that  by  Sir  Astley  Cooper,  as  well  as  by  many  other  experienced  sur- 
geons, its  value  should  have  been  overlooked.  The  chief  obstacle  to 
the  retention  of  the  bone  in  place  is  the  powerful  action  of  the  tra- 
pezius, which  constantly  tends  to  elevate  the  outer  end  of  the  bone. 
In  some  measure  this  may  be  resisted  by  elevating  very  forcibly 
the  shoulder,  or  by  inclining  the  head,  but  both  of  these  positions  are 
extremely  fatiguing,  and  will  not  be  long  endured.  The  bandage  or 
strap,  adjusted  in  the  manner  which  Dr.  Folts  has  recommended,  is  the 
only  means  of  counteracting  the  action  of  the  trapezius,  upon  which 
any  substantial  reliance  can  be  placed  ;  but  the  })rinciple  has  long  been 
understood  and  practised  upon.  Bradsor's  tourniquet,  or  Petit's,  secured 
by  a  strap  brought  under  the  point  of  the  elbow,  Boyer's  double  shoulder- 
straps,  and  Desault's,  third  bandage  all  aimed  at  the  accomplishment 
of  the  same  purpose ;  yet  Boyer  and  Desault  found  all  these  con- 
trivances fail  in  a  majority  of  cases.  Mayor  employed  a  dressing 
constructed  with  a  strap  to  buckle  over  the  dislocated  clavicle,  but 
Nelaton  has  seen  this  apparatus  fail  also,  when  applied  in  his  own 
wards. 

The  experience  of  Dr.  Folts  at  the  time  of  his  report  did  not  ex- 
tend beyond  three  cases,  and  the  apparatus  had  been  completely 
successful  in  only  two  of  the  three.  Our  own  experience  is  sufficient 
to  show  that  it  will  be  found  occasionally,  but  by  no  means  constantly, 
successful.      We  have   already   mentioned  two  cases  in  which  we 

•  Folts,  Bost.  Med.  and  Surg.  Journ.,  vol.  liii.  p.  259. 


536 


DISLOCATIONS    OF    THE    CLAVICLE. 


succeeded  perfectly  by  this  mode,  but  in  several  others  which  seemed 
equally  favorable  we  have  met  with  partial  or  complete  failures. 

The  practical  difficulties  are,  the  sensibility  and  consequent  inability 
sometimes  of  the  point  of  the  elbow  to  bear  the  requisite  pressure, 

and  the  even  greater  sensibility 
Fig.  235.  of  the  skin  over  the  top  of  the 

clavicle ;  the  tendency  of  the 
bandage  to  slide  off  from  the 
shoulder  and  also  to  become 
displaced  from  the  end  of  the 
elbow ;  the  gradual  relaxation 
of  the  bandages,  which,  when 
existing  even  in  the  most  incon- 
siderable degree,  is  sufficient 
sometimes  to  allow  the  bone  to 
slip  out  from  its  shallow  socket; 
the  impossibility  of  fixing  the 
scapula,  upon  whose  immobility 
as  well  as  upon  the  immobility 
of  the  clavicle  the  retention 
depends;  and,  finally,  the  great 
length  of  time  requisite  to  unite 
firmly  the  ligaments,  if  indeed 
they  ever  again  become  actually 
united. 

The  band  can  be  prevented  in 
some  measure  from  sliding  off 
from  the  clavicle  by  a  counter-band  attached  to  a  collar  upon  the 
opposite  shoulder,  but  not  without  causing  some  pain  and  giving  rise 
to  excoriations  generally  in  the  opposite  axilla;  and,  in  a  degree,  all 
the  other  difficulties  may  be  met  by  patience  and  ingenuity,  but  un- 
fortunately the  smallest  failure  in  any  one  of  these  numerous  indica- 
tions insures  a  defeat. 

The  axillary  pad  employed  as  a  fulcrum  upon  which  extension  may 
be  made  is  equally  as  dangerous  here  as  in  fractures,  and  I  do  not 
think  it  ought  ever  to  be  used  for  this  purpose,  but  only  as  a  means 
of  moderate  support  and  retention ;  indeed  it  would  be  well,  perhaps, 
if  it  were  discarded  altogether. 

The  case  of  Mr.  B.,  already  quoted,  with  a  dislocation  outwards  and 
backwards,  affords  not  only  an  illustration  of  the  inefficiency  of  either 
the  shoulder-strap  or  the  axillary  pad  in  certain  cases,  but  also,  it  seems 
to  me,  of  the  mischief  which  may  result  from  their  too  diligent  appli- 
cation ;  for  I  cannot  persuade  myself  but  that  most  of  the  maiming  in 
this  case  was  due  to  the  apparatus  rather  than  to  the  original  accident. 
This  gentleman  was  injured  on  the  10th  of  November,  1855.  A 
sling  with  an  axillary  pad  and  bandages  was  immediately  applied.  I 
saw  him  on  the  seventeenth  day.  The  displacement  was  then  such  as 
I  have  described,  but  I  did  not  observe  any  paralysis  or  emaciation  of 
the  limb.  Having  noticed  that  the  clavicle  fell  into  its  socket  when 
he  lay  upon  his  back  in  bed,  at  my  suggestion  all  the  dressings  ex- 


Mayor's  apparatus  for  dislocated  clavicle.    ("Tri 

angle  cubito-bis-scapulaire.") 


OF    THE    ACROMIAL    END    OF    CLAVICLE    DOWNWARDS.      537 

cept  the  sling  were  removed,  and  the  patient  was  laid  upon  his  back 
in  bed,  with  instructions  to  continue  in  this  position,  if  possible,  until 
the  cure  was  completed ;  but  after  a  few  days  I  received  a  communi- 
cation from  his  physician,  stating  that,  owing  to  a  troublesome  cough, 
he  had  found  it  impossible  to  maintain  this  position.  His  residence 
was  forty  or  fifty  miles  from  town,  and  I  sent  him  one  of  my  dressings 
for  broken  collar-bones  with  instructions  as  to  its  use ;  directing  espe- 
cially that  a  shoulder-strap  should  be  used  to  keep  the  clavicle  down. 

The  dressing  was  applied  and  continued  six  weeks,  and  on  being 
removed,  the  elbow,  wrist,  and  finger  joints  were  found  to  be  stiff. 
The  whole  arm  was  emaciated  and  almost  powerless.  One  year  later 
there  was  no  improvement  in  the  condition  of  the  arm ;  every  joint 
from  the  shoulder  down  was  almost  completely  anchylosed,  the  mus- 
cles were  greatly  wasted,  and  the  hand  trembled  constantly. 

These  results,  it  seems  to  me,  were  due  to  too  long  and  too  tight 
bandaging  of  the  arm,  and  especially  to  the  pressure  of  the  axillary 
pad.     I  do  not  state  this  positively,  but  this  is  my  belief. 

Is  it  worth  while,  then,  to  incur  the  dangers  of  too  long  confinement 
and  of  excessive  bandaging  for  the  purpose  of  attaining  the  always 
uncertain  result  of  maintaining  the  bone  in  its  socket?  We  certainly 
may  be  permitted  to  make  the  attempt  within  certain  reasonable 
limits;  and  especially  if  the  patient  is  a  female  and  the  avoidance  of 
deformity  is  a  point  of  serious  consideration;  but  never  without  keep- 
ing constantly  in  mind  the  possibility  of  a  permanent  anchylosis  and 
paralysis  of  the  limb. 

§  5.  Dislocation  of  the  Acromial  End  op  the  Clavicle  Downwards. 

This  form  of  dislocation  is  exceedingly  rare,  only  three  well-authen- 
ticated cases  having  been  placed  upon  record,  one  of  which  was  seen 
and  dissected  by  Melle  in  1765,  the  second  was  met  with  by  Fleury 
in  1816,  and  the  third  is  described  by  Tournel. 

Cause. — So  far  as  we  can  ascertain,  it  has  been  produced  only  by  a 
force  which  has  acted  directly  upon  the  top  of  the  clavicle.  In  the 
case  mentioned  by  Tournel,  a  horse  had  trod  upon  the  shoulder;  and 
in  the  example  recorded  by  Melle,  the  accident  occurred  in  a  child 
six  years  old,  from  an  attempt  to  support  a  great  weight  upon  the  top 
of  the  collar-bone.  In  this  last  example  the  humerus  was  dislocated 
also,  and  both  dislocations  had  remained  unreduced  many  years  when 
the  patient  was  seen  by  Melle. 

This  force  acting  directly  upon  the  top  of  the  clavicle  would  fail 
to  dislocate  the  bone,  except  by  first  breaking  down  the  coracoid 
process,  if  it  did  not  happen  sometimes  that  at  the  same  moment  the 
lower  angle  of  the  scapula  was  thrown  outwards,  in  such  a  manner 
as  to  depress  slightly  the  coracoid  process,  and  thus  to  permit  the 
outer  end  of  the  clavicle  to  fall  below  the  level  of  the  acromion 
process. 

Sym2Jioms  and  Pathology. — This  dislocation,  whether  it  has  been 
produced  artificially  upon  the  dead  subject  or  accidentally  upon  the 
living,  has  always  been  found  to  be  accompanied  with  a  complete 
35 


588  DISLOCATIOXS    OF    THE    CLAVICLE. 

rupture  of  the  acromio-clavicular  ligaments  not  only,  but  also  of  the 
coraco-acromial  and  coraco-clavicular  ligaments;  the  outer  extremity 
of  the  bone  resting  between  the  acromion  process  and  the  capsule  of 
the  shoulder-joint,  and  a  little  posterior  to  the  articulating  facet  which 
originally  received  the  clavicle. 

The  superior  angle  of  the  scapula  approaches  the  body  slightly, 
and  its  inferior  angle  is  thrown  outwards.  A  marked  depression 
exists  at  the  point  of  dislocation,  accompanied  with  a  sharp  pain, 
increased  especially  when  an  attempt  is  made  to  move  the  arm.  The 
patient  is  unable  to  lift  the  arm  voluntarily,  but  it  can  be  moved 
pretty  freely  in  the  direction  forwards  and  backwards  by  the  hands 
of  the  surgeon :  abduction  is  much  more  difficult. 

Treatment. — Eeduction  is  easily  accomplished.  At  least,  in  the  only 
two  examples  upon  the  living  subject  in  which  the  attempt  has  been 
made,  it  was  eft'ected  promptly  by  drawing  the  shoulders  gently  out- 
wards and  backwards ;  nor  has  it  been  found  any  more  difficult  to 
maintain  it  in  position  when  once  replaced.  When  the  scapula  is 
restored  to  its  natural  position,  and  its  lower  angle  approaches  again 
the  side  of  the  body,  a  reluxation  becomes  impossible;  since  the 
coracoid  process  now  effectually  prevents  that  descent  of  the  clavicle 
upon  which  its  displacement  always  depends.  It  is  only  necessary, 
therefore,  to  secure  the  scapula  at  its  base  and  lower  angle  snugly  to 
the  body,  by  a  broad  band  and  compress,  and  all  the  indications  of 
treatment  are  completely  fulfilled. 

§  6.  Dislocation  of  the  Acromial  End  of  the  Clavicle  under  the 
Coracoid  Process. 

Pinjou  met  with  one  example  of  this  singular  dislocation,'  and 
Godemer,  of  Mayenne,  has  recorded  five  more,^  and  these  constitute 
the  whole  number  which  are  at  this  day  known  to  science. 

Cause. — Age  and  a  consequent  relaxation  of  the  ligaments  seem  to 
constitute  a  predisposing  cause,  since  of  the  six  recorded  examples 
four  were  between  the  ages  of  sixty-seven  and  seventy-one,  and  the 
other  two  were  adults.  In  all  the  cases,  also,  the  dislocation  was  the 
result  of  a  fall  upon  the  shoulder. 

The  symptoms  which  have  been  said  to  characterize  this  accident 
are  pain  and  a  very  marked  depression  at  the  point  of  displacement, 
with  a  corresponding  projection  of  the  acromion  and  coracoid  pro- 
cesses; a  rapid  inclination  outwards  and  downwards  of  the  line  of  the 
clavicle,  its  outer  extremity  being  felt  in  the  axilla ;  the  corresponding 
shoulder  depressed  and  inclined  forwards;  freedom  of  motion  in  all 
directions  except  inwards  and  upwards ;  the  lower  angle  of  the  scapula 
thrown  outwards  and  backwards ;  to  which  Morel-La vallee  has  added 
an  actual  increase  of  space  between  the  acromion  process  and  the 
sternum. 

Treatment. — Godemer  reduced  all  the  examples  which  came  under 
his  notice  easily,  by  directing  an  assistant  to  pull  the  arm  backwards 

'  Pinjou,  Journ.  de.  Med.  de  Lyon,  Juillet,  1842,  from  Vidal  (de  Cassis). 
2  Godemer,  Recueil  des  travaux  de  la  Soc.  Med.  d'Indre  et  Loire,  1843,  from 
Vidal. 


DISLOCATION    AND    EOTATION    FORWARDS.  539 

and  outwards  while  lie  himself  seized  upon  the  clavicle  with  his  fin- 
ders, and  disengaged  it  from  under  the  process;  but  Pinjou,  after 
many  efforts  by  the  same  method,  failed  completely,  and  the  patient 
havino-  left  him,  the  clavicle  was  reduced  the  next  day  by  an  empiric. 
Yidal  (de  Cassis)  recommends  that  instead  of  pulling  the  arm  out- 
wards, by  which  procedure  the  pectoralis  major  is  made  to  antagonize 
the  surgeon,  the  elbow  shall  be  brought  down  to  the  side,  and  kept 
there  by  the  left  hand,  while  the  right  hand,  placed  in  the  axilla,  shall 
pull  the  upper  end  of  the  humerus  outwards,  converting  the  arm  into 
a  lever  of  the  third  kind.  This  process,  I  confess,  seems  to  be  much 
the  most  rational. 

Finally,  having  given  the  history  of  these  cases  as  they  have  been 
reported,  we  shall  scarcely  have  performed  our  duty  as  a  faithful 
writer,  if  we  do  not  state  frankly  that  we  entertain  a  suspicion  that 
both  the  gentlemen  who  have  reported  these  curious  examples  have 
entertained  us  with  fabulous  or  imaginary  stories;  and  especially  do 
these  suspicions  rest  upon  the  cases  reported  by  Godemer,  who  in  five 
years  saw  five  cases,  each  presenting  throughout  the  same  class  of 
symptoms,  the  same  facility  of  reduction,  accomplished  by  the  same 
means,  and  always  with  the  same  perfect  result. 

If  to  these  singular  coincidences  we  add  the  fact  that  only  one  other 
surgeon  has  ever  claimed  to  have  met  with  the  accident,  and  if  we 
notice  the  actual  anatomical  difficulties  which  stand  in  the  way  of  its 
occurrence,  such  especially  as  the  complete  occlusion  of  the  subcora- 
coidean  space  by  the  tendons  and  muscles  which  pass  from  its  extre- 
mity toward  the  chest  and  arm,  we  shall  find  a  fair  apology  for  some 
degree  of  scepticism. 

§  7.  Dislocation  and  Rotation  Foravards  of  the  Clavicle  at  both 
Ends,  Simultaneously. 

The  following  example  is  the  only  one  of  this  kind  of  which  I  have 
any  knowledge : — 

On  the  26th  of  January,  1863,  Dr.  North,  of  Brooklyn,  N.  Y.,  was 
called  to  see  a  lad  fourteen  years  of  age,  who  had  been  thrown  with 
violence  backwards  from  a  stool  upon  which  he  was  sitting,  striking 
the  back  of  his  left  shoulder  against  the  floor.  Dr.  North  found  him 
suffering  severely  from  pain,  and  with  some  difficulty  of  breathing. 
The  shoulder  was  depressed  and  thrown  forwards.  The  sternal  end 
of  the  clavicle,  turned  forwards,  formed  an  abrupt,  roiyided  promi- 
nence ;  the  acromial  end,  turned  forwards  also,  presented  its  longest 
diameter  toward  the  surface,  and  rested  above  the  acromion  process ; 
while  the  central  portion  seemed  depressed  or  thrown  back,  an  ap- 
pearance which  was  caused  by  the  rotation  of  the  clavicle  upon  its  axis. 

Reduction  was  accomplished  by  throwing  the  shoulders  forcibly 
backwards,  and  at  the  same  time  pressing  with  the  thumbs  upon  the 
two  extremities  in  such  a  manner  as  to  reverse  the  rotation,  as  follows: 
pressing  at  the  acromial  end  backwards  and  downwards,  and  at  the 
sternal  end  backwards  and  upwards.  The  restoration  was  complete, 
and  the  bones  were  retained  in  place  by  compresses  and  adhesive 


540  DISLOCATIONS    OF    THE    SHOULDER. 

plasters,  with  the  aid  of  Day's  "  neck  yoke."  At  the  end  of  three 
weeks  the  dressings  were  removed ;  and  when  last  seen  by  bis  sur- 
geon "  there  was  but  little,  if  any,  trace  of  the  accident  remaining." 
It  is  the  opinion  of  Dr.  North  that  the  rotation  was  caused  by  the 
action  of  the  pectoralis  major  and  deltoid  after  the  dislocation  took 
place.' 


C  H  A  P  T  E  R  V I . 

DISLOCATIONS  OF  THE  SHOULDER  (HUMERUS  AT  ITS  UPPER 
EXTREMITY). 

Owing  to  the  great  exposure,  and  the  peculiar  anatomical  structure 
of  the  shoulder-joint,  its  structure  having  reference  mainly  to  freedom 
of  motion  rather  than  to  firmness  and  security  in  the  articulation, 
dislocations  of  the  humerus  are  very  common. 

Writers  have  not  been  agreed  as  to  the  precise  anatomical  relations 
of  these  dislocations,  nor  as  to  the  nomenclature.  Velpeau,  Malgaigne, 
Yidal  (de  Cassis),  Skey,  and  Sir  Astley  Cooper  have  each  adopted 
explanations  and  classifications  peculiar  to  themselves.  With  the 
arrangement  established  by  this  latter  surgeon,  English  and  American 
students  are  the  most  familiar;  and  believing  that  it  is  more  simple, 
and  quite  as  appropriate  as  either  of  the  others,  I  shall  adopt  it  as  the 
basis  of  my  own  descriptions. 

I  shall  have  occasion,  however,  to  dissent  from  the  opinions  and 
teachings  of  this  distinguished  surgeon,  as  to  the  exact  seat  and  rela- 
tions of  the  head  of  the  humerus  in  some  of  these  dislocations. 

According  to  Sir  Astley  Cooper,  there  are  three  complete  luxations 
of  the  shoulder,  namely,  downwards,  forwards,  and  backwards. 

§  1.  Dislocation  of  the  Shoulder  Downwards  (Subglenoid). 

This  is  usually  called  a  dislocation  into  the  axilla ;  the  head  of  the 
bone  resting  rather  upon  the  inner  side  of  the  inferior  border  of  the 
scapula,  near  the  base  of  that  triangular  surface  which  is  found  below 
the  glenoid  fossa. 

Since  in  both  the  other  complete  dislocations  of  the  shoulder,  the 
head  of  the  humerus,  in  order  to  escape  from  its  socket,  must  be  made 
to  descend  more  or  less  downwards,  we  shall  regard  this  dislocation 
as  the  type  of  all  the  others,  and  shall  make  it  the  subject  of  especial 
consideration  as  well  as  of  reference  when  speaking  of  the  other  forms 
of  dislocation. 

Causes. — The  most  frequent  cause  of  this  accident  is  a  blow  received 
directly  upon  the  upper  end  and  outer  surface  of  the  humerus.  I  have 
found  the  arm  dislocated  into  the  axilla  by  this  cause  eleven  times; 

'  N.  L.  North,  M.D.,  New  York  Med.  Record,  April  ICtli,  1866. 


DISLOCATION"    OF    THE    SHOULDER    DOWNWARDS.       54:1 

four  times  by  a  fall  upon  the  extended  hand;  once  by  a  fall  upon  the 
elbow,  and  in  this  latter  case  the  arm  was  probably  carried  away  from 
the  body  at  the  moment  of  the  receipt  of  the  injury. 

In  all  the  above  examples  the  shoulder  has  been  dislocated  by  the 
simple  force  of  the  blow,  or  with  only  slight  aid  from  muscular  action ; 
but  in  a  considerable  number  of  cases  the  bone  is  displaced  almost 
wholly  by  the  action  of  the  muscles,  the  arm  having  been  previously 
violently  abducted  ;  and  perhaps  in  some  cases  the  capsule  being  torn 
before  the  resistance  of  the  overstrained  muscles  has  accomplished  the 
displacement.  Thus,  in  three  instances  I  have  known  the  dislocation 
to  result  from  holding  on  to  the  reins  after  being  thrown  from  a  car- 
riage; in  two  cases  the  patients  have  fallen  through  a  hatchway  and 
been  caught  and  suspended  by  the  arms;  once  a  woman  met  with 
this  accident  by  holding  on  to  a  pump-handle  when  she  had  slipped 
and  fallen  upon  the  ice.  A  few  years  since  I  examined  the  arm  of  a 
Swiss  woman,  Maria  Norregan,  who  was  then  sixty-five  years  old,  and 
whose  humerus  had  been  dislocated  into  the  axilla  seventeen  years 
before,  where  it  still  remained.  Her  own  account  of  the  accident  was, 
that  she  was  returning  from  the  Jura  Mountains,  near  Neufchatel,  with 
a  load  of  hay  upon  her  head.  She  had  carried  it  a  long  way  with  her 
hands  held  upwards,  without  once  stopping  to  rest,  and  when  at  length 
she  threw  down  the  load  at  her  door,  the  right  shoulder  was  dislocated. 
The  arm  soon  became  very  painful,  and  swollen  to  the  fingers'  ends; 
but  she  was  too  remote  from,  and  too  poor  to  employ,  a  surgeon.  A 
tailor,  who  used  to  do  the  minor  surgery  of  the  neighborhood,  bled 
her  three  or  four  times,  but  the  dislocation  was  not  recognized  until 
many  months  after. 

A  Mrs.  Hunn  informed  me  that  when  she  was  twenty-two  years  old 
she  had  a  convulsion,  and  that  her  attendants  in  trying  to  hold  her 
upon  her  bed,  actually  pulled  the  shoulder  out  of  joint.  After  the 
first  accident  the  dislocation  was  not  repeated  for  four  years,  but  since 
then  it  had  occurred  from  very  slight  causes  many  times.  She  was 
in  the  habit  of  reducing  it  herself  by  placing  a  ball  in  the  axilla  and 
using  the  arm  as  a  lever. 

Dr.  Lehman  reports  the  case  of  a  sailor  on  board  an  American  brig, 
who  was  subject  to  a  dislocation  into  the  axilla  from  very  slight 
causes,  and  especially  if  he  bent  his  body  far  over  to  raise  anything. 
He  could  also,  by  pulling  horizontally,  remove  the  head  of  the  bone 
from  its  socket.  It  was  reduced  easily,  and  he  experienced  no  pain 
either  in  the  reduction  or  dislocation,  nor,  indeed,  during  the  displace- 
ment.^ 

Pathology. — In  this  accident  the  head  of  the  bone  is  made  to  press 
against  the  capsule  below  and  immediately  in  front  of  the  long  head 
of  the  triceps,  until  the  capsule  gives  way,  and  continuing  to  descend 
in  the  same  direction  it  is  finally  arrested  by  the  triangular  surface 
of  the  inferior  edge  of  the  scapula  immediately  below  the  glenoid 
fossa.  Owing  to  the  pressure  of  the  tendon  of  the  triceps  behind,  it 
occupies  a  position  also  a  little  in  advance  of  the  centre  of  this  triangle, 

'  Leliman,  Amer.  Jouru.  Med.  Sci.,  vol.  i.  p.  242,  1838. 


542 


DISLOCATIONS    OF    THE    SHOULDER. 


Fiff.  236. 


or  rather  upon  its  anterior  edge,  so  that  it  rests  more  or  less  upon  the 

belly  of  the  subscapularis  muscle. 

The  capsule  is  generally  torn  quite  extensively,  especially  below 

and  in  front;  and  the  tendon  of  the  long  head  of  the  biceps  may  be 

broken  asunder,  or  detached 
completely  from  its  insertion; 
the  supra-spinatus  muscle  is 
stretched  or  lacerated ;  the 
infra-spinatus,  subscapularis, 
and  coraco-brachialis  are  put 
upon  the  stretch  ;  the  subscapu- 
laris being  also  sometimes  com- 
pletely torn  from  its  attachment 
to  the  head  of  the  humerus,  and 
in  either  case,  whether  torn 
merely     compressed     and 


or 

stretched,  the  circumflex  nerve, 
which  runs  along  its  lower 
margin,  is  subject  to  severe  in- 
jury ;  the  deltoid  muscle  is  also 
placed  in  a  condition  of  ex- 
treme tension ;  while  the  teres 
major  and  minor  in  this  respect 
are  subjected  to  but  little 
change. 

In  some  cases  a  portion  or 
the  whole  of  the  greater  tuberosity  is  completely  detached,  and  the 
fragment  displaced  by  the  action  of  the  muscles  inserted  into  it. 

Symptoms. — A  palpable  depression  immediately  under  the  extrem- 
ity of  the  acromion  process,  more  distinct  in  children,  in  very  old 
and  in  thin  people,  than  in  adults  of  middle  life  or  than  in  fat  or 
muscular  people,  but  never  absent  completely,  unless  the  shoulder  is 
very  much  swollen;  the  elbow  carried  out  from  the  body  three  or 
four  inches,  sometimes  a  little  backwards,  and  the  line  of  its  axis 
directed  toward  the  axilla;  the  outer  surface  of  the  arm  presenting 
two  planes  inclined  toward  each  other,  and  meeting  at  the  point  of 
insertion  of  the  deltoid  muscle;  the  head  of  the  humerus  felt  in  the 
axilla,  particularly  when  the  elbow  is  carried  away  from  the  body ; 
numbness  of  the  arm,  accompanied  generally  with  pain,  especially 
when  any  attempt  is  made  to  press  the  elbow  against  the  side; 
rigidity  with  inability  to  move  the  arm  freely  in  any  direction,  but 
especially  inwards;  allowing,  however,  of  pretty  free  passive  motion, 
but  not  permitting  the  elbow  to  touch  the  body  without  great  pain, 
which  pain  is  occasioned  mostly  by  the  pressure  of  the  humerus  upon 
the  axillary  plexus;  under  no  circumstance  can  the  hand  be  placed 
upon  the  opposite  shoulder  while  at  the  same  moment  the  elbow 
touches  the  thorax ;  the  head  of  the  patient,  and  sometimes  the  whole 
body,  inclined  toward  the  injured  arm;  the  arm  lengthened  from  half 
an  inch  to  an  inch ;  a  chafing  or  friction  sound  is  not  unfrequently 
present,  especially  if  the  bone  has  been  some  days  dislocated ;  but 


Dislocation  of  the  shoulder  downwards  into  the  ax- 
illa.    (Subglenoid.) 


DISLOCATION    OF    THE    SHOULDER    DOWNWARDS.        543 

Mr.  Lawrence  mentions  a  case  in  which  there  was  a  distinct  crepitus, 
yet  there  was  no  fracture ;  Dr.  Hays  saw  a  similar  case  in  Wills 
Hospital,  Philadelphia,  in  a  woman  sixty  years  old,  whose  arm  had 
been  dislocated  forwards  eiofht  weeks.^     Other  surgeons  have   related 


Dislocation  of  the  shoulder  downwards  into  the  axilla.     (Subglenoid.) 

like  examples,  but  it  is  probable  that  in  all  these  cases  there  has  been 
an  exposure  of  the  bone  at  or  near  the  edge  of  the  glenoid  fossa,  by 
the  partial  detachment  of  its  ligamentous  margin,  or  some  portion  of 
the  head  has  become  divested  of  its  cartilaginous  covering.  (For  a 
more  complete  differential  diagnosis,  see  chapter  on  fractures  of  the 
humerus.) 

Decisive  as  these  signs  usually  are  of  the  true  nature  of  the  accident, 
cases  will  every  now  and  then  occur  in  which  the  diagnosis  will  be 
attended  with  great  dif&culty,  and  especially  if  a  few  hours  have  been 
permitted  to  elapse  since  the  occurrence  of  the  injury,  so  that  consid- 
erable effusions  of  blood  and  of  lymph  may  have  taken  place;  while 
at  a  still  later  period,  when  the  swelling  has  subsided,  the  diagnosis 
again  becomes  easy.  "  At  this  latter  period,"  says  Sir  Astley  Cooper, 
"  it  is  that  surgeons  of  the  metropolis  are  usually  consulted ;  and  if  we 
detect  a  dislocation  which  has  been  overlooked,  it  is  our  duty  in  can- 
dor to  state  to  the  patient  that  the  difficulty  of  detecting  the  nature  of 
the  accident  is  exceedingly  diminished  by  the  cessation  of  inflamma- 
tion, and  the  absence  of  tumefaction." 

It  has  never  happened  to  me  to  have  seen  a  case  of  dislocation  into 
the  axilla  which  I  have  not  easily  recognized,  but  in  my  report  to  the 

'  Lawrence,  Hays,  Amer.  Journ.  Med.  Sci.,  vol.  xxiv.  p.  33G,  May,  1839. 


544  DISLOCATIONS    OF    THE    SHOULDER. 

New  York  State  Medical  Society,  already  referred  to,  I  have  related 
two  cases  which  were  not  recognized  by  the  patients  themselves,  and 
no  surgeon  was  called  until  after  several  days  or  weeks,  and  three 
cases  in  which  empirics  having  been  employed  they  failed  to  detect 
the  dislocation,  and  since  the  date  of  the  report,  I  have  met  with  many 
similar  examples  which  had  not  been  recognized  by  intelligent  sur- 
geons. Although,  therefore,  I  am  prepared  to  admit  the  justness  of  the 
observations  made  by  Sir  Astley  Cooper,  I  think  that  if  the  case  is 
seen  within  an  hour  or  two  after  the  accident,  its  nature  may  be  gene- 
rally determined  promptly  by  the  surgeon  of  experience;  but  upon 
this  subject  I  have  already  spoken  very  fully  in  the  chapter  on  frac- 
tures of  the  humerus;  and  from  the  examples  and  opinions  which  I 
have  there  presented  it  will  be  inferred  that  it  is  much  more  common 
to  mistake  a  fracture  for  a  dislocation,  than  a  dislocation  for  a  fracture, 
an  observation  which  is  equally  as  applicable  to  dislocations  forwards 
as  to  the  form  of  dislocation  now  under  consideration. 

Prognosis. — If  the  force  which  displaced  the  bone  was  not  great,  or 
if  the  shoulder-joint  has  not  suffered  any  injury  from  the  accident 
itself  beyond  the  mere  rupture  of  the  capsule  and  a  moderate  straining 
of  the  muscles,  and  if  the  dislocation  has  been  early  and  easily  reduced, 
the  patient  is  immediately  after  the  reduction  able  to  move  the  arm 
freely  in  all  directions ;  very  little  swelling  follows,  and  in  a  short 
time  a  perfect  restoration  of  all  the  functions  of  the  limb  is  accom- 
plished. 

It  cannot,  however,  always  be  inferred  from  the  degree  of  violence 
employed  in  the  production  of  the  dislocation,  nor  from  the  absence 
or  presence  of  swelling,  how  much  injury  the  tendons,  muscles,  and 
nerves  have  suffered,  since  the  same  causes  produce  greater  lesions  in 
one  person  than  in  another,  and  the  amount  of  swelling  may  depend 
upon  the  accidental  rupture  of  an  unimportant  bloodvessel,  or  upon 
some  peculiarity  in  the  constitution  of  the  patient  predisposing  to 
serous,  fibrous,  or  sanguineous  effusions. 

To  whatever  cause  we  may  find  occasion  to  attribute  the  result,  it 
will  nevertheless  be  observed  that,  in  a  great  majority  of  cases,  the 
limb  is  not  restored  to  all  its  original  strength  and  freedom  of  motion 
until  after  the  lapse  of  some  months ;  and  the  shoulder  does  not  re- 
sume its  perfect  form  and  symmetry  until  a  much  later  period ;  occa- 
sional pains,  especially  after  exercise  of  the  muscles,  and  in  certain 
conditions  of  the  weather,  are  present  also  at  irregular  intervals  and 
for  indefinite  periods  of  time.  Opposite  and  more  favorable  termina- 
tions must  be  regarded  as  exceptions  to  the  rule. 

Where  the  reduction  has  been  made  within  a  few  hours,  I  have 
found  the  shoulder  affected  with  muscular  anchylosis  with  more  or 
less  weakness  of  the  arm  after  a  lapse  of  from  a  few  days  to  one  or 
two  years. 

A  laborer,  set.  41,  had  dislocated  his  right  shoulder  into  the  axilla. 
Dr.  H.,  an  intelligent  young  surgeon,  reduced  the  bone  easily  with  his 
hands  alone,  while  the  patient  was  still  unconscious  from  the  shock  of 
the  injury.  After  six  weeks  he  called  upon  me,  accompanied  by  his 
surgeon,  thinking  that  it  was  not  properly  reduced  because  the  arm 


DISLOCATIOISr    OF    THE    SHOULDER    DOWNWAEDS.       545 

was  still  painful,  and  he  could  not  move  it  freely.  The  bone  was, 
however,  well  in  its  socket.  One  year  later  I  examined  this  man,  and 
found  some  anchylosis  remaining  in  the  shoulder-joint. 

James  Rogers,  set.  39,  fell  while  running  and  struck  upon  his  right 
shoulder.  Dr.  Eastman,  Prof,  of  Anatomy  in  the  Buffalo  Medical 
College,  reduced  the  dislocation  four  hours  after  the  occurrence,  in 
the  following  manner :  The  patient  being  seated  in  a  chair.  Dr.  East- 
man placed  his  knee  in  the  axilla  and  manipulated,  while  one  assistant 
supported  the  acromion  process,  and  another  pulled  downwards  npon 
the  forearm.  The  time  occupied  in  the  reduction  was  about  two 
minutes,  and  the  bone  finally  resumed  its  position  with  a  snap  audible 
to  all  the  persons  in  the  room.  For  some  months  after,  and  at  the 
period  when  I  was  invited  to  see  him,  the  muscles  about  the  shoulder 
were  rigid,  and  the  motions  of  the  joint  embarrassed ;  but  at  the  end 
of  two  years,  Dr.  Eastman  informed  me  that  the  joint  had  become  free 
and  the  arm  as  useful  as  before,  except  that  he  could  not  throw  a 
stone. 

In  another  case,  a  gentleman  residing  in  an  adjoining  county,  aet. 
42,  was  thrown  from  his  carriage,  falling  forwards  upon  his  hands. 
The  dislocation  was  reduced  promptly,  by  placing  the  heel  in  the 
axilla,  and  within  fifteen  minutes  after  it  had  occurred.  Three  months 
after  this  the  patient  consulted  me  on  account  of  the  immobility  of 
the  shoulder-joint,  and  because  several  surgeons  had  expressed  a 
doubt  whether  it  was  properly  reduced.  The  anchylosis  was  then  so 
complete  that  the  humerus  could  not  be  moved  separately  from  the 
scapula,  but  there  was  no  displacement.  This  gentleman  again  called 
upon  me  at  the  end  of  four  years,  and  I  then  found  the  arm  nearly 
restored  to  its  original  condition,  but  it  was  not  quite  so  strong  as 
before.  He  experienced  also  "  curious"  sensations  in  his  arm  and 
hand  occasionally.  The  anchylosis  had  continued  with  very  little 
improvement  about  two  years,  after  which  it  had  been  gradually  dis- 
appearing. 

I  need  scarcely  say  that  in  those  examples  in  which  the  reduction 
of  the  bone  has  been  delayed  beyond  a  few  hours,  or  for  several  days 
or  weeks,  the  continuance  of  the  anchylosis  has  been  more  persistent ; 
but  in  no  case  which  has  come  under  my  observation,  unless  the  bone 
still  remained  unreduced,  has  the  anchylosis  been  permanent.  For 
this  reason  I  am  disposed  to  think  that  muscular,  rather  than  fibrous 
or  ligamentous  anchylosis,  is  the  cause,  generally,  of  the  immobility 
of  the  joint.  I  have  certainly  never  in  any  instance  met  with  a  true 
bony  anchylosis  as  a  consequence  of  a  shoulder  dislocation.  The  an- 
chylosis in  question  seems  to  be  a  result  simply  of  laceration  or  more 
generally  of  a  severe  strain  of  the  muscular  fibres,  resulting  in  in- 
flammation and  a  contraction  of  these  fibres ;  and  its  occurrence  in 
any  particular  case  may  therefore  be  justly  attributable  either  to  the 
position  of  the  bone  when  it  is  dislocated,  to  the  force  of  the  blow 
which  has  produced  the  dislocation,  or  to  the  violence  applied  in  the 
attempts  at  reduction. 

Paralysis  and  wasting  of  the  muscles  of  the  arm,  either  with  or 
without  muscular  contraction  and  rigidity,  are  also  observed  in  a  cer- 


54:6  DISLOCATIONS    OF    THE    SHOULDER. 

tain  number  of  cases.  Especially  has  it  been  noticed  that  the  deltoid 
muscle  is  liable  to  atrophy ;  and  in  their  attempts  to  explain  the  fre- 
quency of  its  occurrence  in  this  latter  muscle,  surgeons  have  generally 
referred  to  a  probable  rupture  of  the  circumflex  nerve,  a  circumstance 
which  the  autopsies  show  does  occasionally  take  place ;  or  to  a  mere 
stretching  of  this  nerve ;  yet  it  is  quite  as  fair  to  presume  that  in 
many  cases  it  is  due  solely  to  the  greater  injury  which  the  deltoid 
muscle  has  sustained  by  the  unnatural  position  of  the  head  of  the 
bone  during  the  continuance  of  the  dislocation,  for,  with  the  exception 
of  the  supra-spinatus,  it  is  placed  more  upon  the  stretch  than  any  other. 
Nor  is  it  improbable  that  in  some  cases  it  is  due  to  the  mere  force  of 
the  blow  which,  having  been  received  directly  upon  the  top  of  the 
shoulder,  has  contused  the  muscle.  In  short,  any  of  the  causes  which 
may  determine  in  the  deltoid  inflammation  and  consequent  rigidity, 
must  finally  result  in  desuetude  and  consequent  atrophy. 

In  quite  a  number  of  cases  my  attention  has  been  called  to  a  re- 
markable fulness  just  in  front  of  the  head  of  the  bone,  which  has 
continued  sometimes  for  many  months  and  even  years  after  the  re- 
duction has  been  effected,  the  patients  having  in  several  cases  applied 
to  me  to  know  whether  this  did  not  indicate  that  the  bone  was  not  in 
its  socket,  especially  as  it  has  been  usually  attended  with  some  stiff- 
ness in  the  joint.  Not  unfrequently  I  have  been  told  that  surgeons 
who  had  noticed  this  fulness,  thought  the  bone  was  not  reduced;  and 
in  one  instance  I  am  informed  that  a  jury  returned  a  verdict  against 
the  surgeon,  where  there  was  no  other  evidence  of  malpractice  than 
this  fulness  with  some  anchylosis,  but  which,  in  the  opinion  of  these 
gentlemen,  was  conclusive  evidence  that  the  bone  was  not  properly 
set.  The  deception  is  also  often  the  more  complete  from  the  fact  that 
there  may  exist  a  corresponding  depression  underneath  the  acromion 
process,  behind. 

It  may  be  present  where  but  little  force  has  been  used,  either  in  the 
production  of  the  dislocation,  or  in  its  reduction.  I  have  seen  it  in  a 
girl,  only  fourteen  years  of  age,  who  had  dislocated  her  left  shoulder 
into  the  axilla,  by  a  fall  upon  a  slippery  side-walk.  I  reduced  the 
bone,  assisted  by  Dr.  George  Burwell,  within  half  an  hour  after  the 
accident.  Dr.  Burwell  held  upon  the  acromion  process  while  I  lifted 
the  arm  to  a  right  angle  with  the  body,  and  pulled  gently,  and  the 
reduction  was  at  once  accomplished  ;  but  we  immediately  noticed  that 
the  head  of  the  bone  seemed  to  press  forwards  in  the  socket  so  as  to 
resemble  what  Sir  Astley  Cooper  has  described  as  a  partial  forward 
luxation.  There  was  also  a  corresponding  depression  behind.  Carry- 
ing the  elbow  back  rendered  the  projection  more  decided,  but  bringing 
it  forwards  would  not  make  it  entirely  disappear. 

In  other  instances  much  more  difficulty  has  been  experienced,  and 
more  force  has  been  employed  in  the  reduction.  A  man  weighing 
two  hundred  pounds,  and  forty-one  years  of  age,  residing  at  Bath,  in 
Steuben  Co.,  fell  from  a  load  of  hay  in  May,  1853,  striking  upon  the 
top  and  front  of  the  left  shoulder.  It  was  immediately  ascertained 
that  he  had  dislocated  his  arm  into  the  axilla,  and  broken  his  leg.  A 
young  surgeon  attempted  within  a  few  minutes  to  reduce  the  disloca- 


DISLOCATION    OF    THE    SHOULDER    DOWNWAEDS.       5-i7 

tioD,  but  failed;  and  about  two  hours  later  it  was  reduced  by  another 
surgeon,  with  the  aid  of  chloroform  and  Jarvis's  adjuster.  Four  years 
after  the  accident  had  occurred,  this  gentleman  came  to  me  accom- 
panied by  the  surgeon  who  had  made  the  reduction,  in  consequence 
of  its  having  been  intimated  by  some  medical  men  that  it  was  not 
properly  reduced.  The  arm  was  not  as  strong  as  the  other;  some 
anchylosis  existed  at  the  shoulder-joint;  but  especially  it  was  noticed 
that  there  still  remained  a  remarkable  fulness  in  front,  as  if  the  head 
of  the  bone  was  pressed  forwards.  By  no  manipulation  or  position 
could  this  fulness  be  made  to  disappear,  yet  the  bone  was  plainly 
enough  in  its  socket. 

This  phenomenon  is  probably  due  in  some  cases  to  a  rupture  of  the 
supra-spinatus  muscle,  and  the  consequent  preponderating  action  of 
the  antagonizing  muscles,  or  to  the  laceration  of  the  capsule,  but  most 
often,  I  imagine,  to  a  rupture  or  to  a  displacement  of  the  long  head  of 
the  biceps,  a  circumstance  to  which  I  shall  more  particularly  allude 
under  the  subject  of ''partial  dislocations." 

Among  the  results  of  this  dislocation  must  be  placed  a  tendency  to 
reluxation,  which,  although  it  may  not  often  be  made  manifest  by  its 
actual  occurrence,  owing  perhaps  to  the  prudence  of  the  surgeon,  yet 
it  does  take  place  in  a  sufficient  number  of  cases  to  establish  its 
peculiar  liability.  Indeed,  we  need  only  consider  how  imperfect  is 
the  protection  against  this  accident,  when  once  the  capsule  has  been 
torn,  to  appreciate  this  observation.  Examples  of  spontaneous  luxa- 
tion, or  of  luxation  of  the  shoulder  from  very  trivial  causes,  after  it 
has  once  been  luxated,  may  be  found  in  the  experience  of  almost 
every  surgeon.  I  have  myself  met  with  several  persons  who  have 
had  repeated  luxations  from  a  slight  cause,  and  in  some  instances, 
where  the  patients  were  subject  to  epilepsy,  the  luxations  have  oc- 
curred whenever  the  convulsions  returned. 

A  gentleman  residing  at  Toronto,  Canada  West,  had  a  dislocation 
of  the  right  shoulder  into  the  axilla  when  he  was  quite  a  child,  and 
the  accident  was  renewed  when  twenty-nine  years  old  by  falling  from 
a  carriage  head  foremost,  with  his  right  arm  extended  and  uplifted. 
Since  then,  until  he  called  upon  me,  a  period  of  about  six  years,  he 
has  been  constantly  subject  to  the  same  dislocation ;  and  he  cannot 
raise  his  arm  high  above  his  shoulders  without  producing  a  subluxa- 
tion, the  head  of  the  humerus  resting  upon  the  outer  margin  of  the 
lower  and  anterior  edge  of  the  glenoid  fossa,  but  by  rotating  the  arm 
outwards  it  immediately  resumes  its  place.  I  found  the  whole  limb 
as  fully  developed,  and  he  said  it  was  quite  as  strong,  as  the  opposite 
limb. 

I  have  already  mentioned  the  case  of  Mrs.  Hunn,  whose  arm  had 
been  dislocated  more  than  twenty  times  in  the  last  five  years;  and  I 
remember  a  lad,  Pat.  Dolan,  aged  nineteen  years,  whose  left  arm  was 
dislocated  by  falling  from  the  mast-head  of  a  vessel,  and  hanging  by 
his  hand.  No  attempt  was  made  to  reduce  it  until  fourteen  hours 
after  the  accident,  at  which  time  it  was  set  by  two  German  doctors, 
but  not  until  they  had  pulled  upon  it  three  hours.  Four  months  after 
it  was  again  dislocated  by  the  slipping  of  an  oar  while  he  was  rowing 


518  DISLOCATIONS    OF    THE    SHOULDER. 

a  boat.  A  surgeon  having  failed  this  time  to  bring  it  into  place,  I 
succeeded  readily  and  without  the  aid  of  an  anassthetic,  by  raising 
the  arm  directly'upwards  in  the  line  of  the  body,  while  ray  foot  was 
pressed  upon  the  top  of  the  scapula.  Many  other  similar  examples 
have  come  under  my  notice. 

We  have  referred  more  than  once  to  the  occasional  difficulty  of 
diagnosis  in  this  as  well  as  in  many  other  shoulder  accidents ;  and  I 
have  alluded  to  five  cases  in  which  the  dislocation  was  not  recognized, 
but  none  of  them  had  been  seen  by  a  surgeon.  Other  writers  have, 
however,  mentioned  many  examples  of  unreduced  dislocations  of  the 
shoulder,  for  which  surgeons  of  skill  and  experience  were  responsible. 
I  have  myself  met  with  these  cases  quite  often.  For  example,  I  have 
seen  two  dislocations  of  the  humerus  into  the  axilla,  both  of  which 
had  been  seen  and  examined  by  New  York  hospital  surgeons  within 
a  few  hours  after  the  receipt  of  the  injury,  but  the  nature  of  the  ac- 
cident had  not  been  recognized.  One  of  these  I  reduced  at  Bellevue 
Hospital  on  the  seventh  day,  and  one  on  the  tenth.  There  was  also 
presented  to  me,  at  the  Charity  Hospital  (Blackwell's  Island),  in  my 
service,  an  axillary  dislocation  of  twenty  years'  standing,  which  a 
surgeon  saw  immediately  after  the  receipt  of  the  injury  and  failed  to 
recognize.  In  other  cases  the  dislocation  has  been  clearly  made  out, 
but  the  surgeon  has  been  unable  to  reduce  the  bone.  It  has  been  my 
fortune  to  succeed  in  several  instances  where  others  have  made  a  fair 
trial  and  have  failed,  but  the  following  case  leaves  me  no  opportunity 
to  boast  the  superiority  of  my  own  skill  above  that  of  my  confrh-es. 

Mary  Kanally,  set.  49,  a  large,  fat,  laboring  woman,  was  admitted 
into  the  Buffalo  Hospital  of  the  Sisters  of  Charity,  with  a  dislocation 
of  the  right  humerus  into  the  axilla,  which  had  occurred  twelve  hours 
before.  This  is  the  same  woman  of  whom  I  have  before  spoken  as 
having  produced  the  dislocation  by  a  fall  while  holding  upon  the 
handle  of  a  pump. 

Drs.  Lockwood  and  Baker,  of  Buffalo,  were  first  called,  and  at- 
tempted reduction.  They  made  extension  and  counter-extension  in 
every  possible  direction,  and  for  a  long  time,  but  to  no  purpose.  She 
was  then  sent  to  the  hospital.  Without  attempting  to  describe  mi- 
nutely the  various  modes  of  extension  and  manipulation  which  I 
employed,  I  will  briefly  state  that,  having  placed  her  completely 
under  the  influence  of  chloroform,  the  manipulations  were  made 
assiduously  during  one  hour,  without  success.  On  the  following 
morning  she  was  bled  freely  from  the  opposite  arm,  and  chloroform 
again  administered;  extension  being  made,  in  the  presence  of  Prof. 
Charles  A.  Lee  and  other  gentlemen,  with  Jarvis's  adjuster.  After 
more  than  an  hour,  the  eflbrt  was  again  suspended.  On  the  following 
day  we  made  a  third  attempt,  the  patient  being  completely  under  the 
influence  of  chloroform,  but  with  no  better  success.  The  chloroform 
produced  a  condition  approaching  apoplexy,  and  it  was  not  again 
used.  On  the  tenth  day,  assisted  by  Prof.  James  P.  White  and  other 
surgeons,  we  applied  the  compound  pulleys,  moving  the  arm  in  vari- 
ous directions.  Twice  we  thought  the  reduction  was  accomplished, 
but  as  often  as  we  proceeded  to  examine  it  attentively  we  found  it 


DISLOCATION    OF    THE    SHOULDER    DOWNWARDS. 


549 


Fiff.  238. 


New  socket,  in  an  ancient  luxation  of 
the  sliouliier  downwards.  (From  Sir  A. 
Cooper.) 


was  not.     If  it  did  ever  pass  into  the  socket,  it  was  immediately 

displaced. 

The  woman  after  this  refused  to  submit  to  any  further  attempts,  and 

she  soon  left  the  hospital,  nor  have  I  seen  or  heard  from  her  since. 
Sir  Astley  Cooper  has  thus  described 

the  appearances  presented  on  dissection 

of  a  dislocation  which  had  been  long 

unreduced :    "  The    head   of  the  bone 

altered  in  its  form;  the  surface  towards 

the  scapula  being  flattened.     A  com- 
plete capsular  ligament  surrounding  the 

head  of  the  os  humeri.     The  glenoid 

cavity  entirely  filled    by  ligamentous 

matter,  in  which  were  suspended  small 

portions  of  bone,  which  were  of   new 

formation,  as  no  portion  of  the  scapula 

or  humerus  was  broken.    A  new  cavity 

formed  for  the  head  of  the  os  humeri 

on  the  inferior  costa  of  the  scapula; 

but  this  was  shallow,  like  that   from 

which  the  bone  had  escaped." 

When  the  dislocation  into  the  axilla 

remains  unreduced,  the    consequences 

are  always  sufficiently  grave,  but  they  differ  very  much  in  degree,  in 

character,  and  in  persistence,  according  as  the  arm  has  remained  a 
lonsfer  or  shorter  time  unreduced,  and  according  to  the  presence  or 
absence  of  complications.  These  conditions  will  be  best  illustrated 
by  a  reference  to  examples. 

Wm.  S.,  a  German,  set.  51,  fell  down  a  flight  of  steps  while  intoxi- 
cated, producing  a  dislocation  of  the  left  arm  into  the  axilla.  Eleven 
hours  after  the  accident,  he  was  received  into  the  Buffalo  Hospital  of 
the  Sisters  of  Charity.  No  attempt  had  been  made  to  reduce  the  bone. 
The  reduction  was  effected  by  myself  with  tolerable  ease,  by  extending 
the  arm  perpendicularly  above  the  head,  while  my  foot  pressed  upon 
the  top  of  the  scapula.  The  head  of  the  humerus  could  be  plainly  felt 
in  the  axilla,  approaching  the  socket,  until  it  seemed  to  be  directly  over 
it,  when,  on  lowering  the  arm,  it  was  found  to  be  reduced.  After  the 
reduction,  the  patient  could  not  raise  the  arm  more  than  eight  inches 
from  the  body.  The  fingers,  hand,  and  forearm  were  almost  paralyzed. 
Three  weeks  later,  when  he  left  the  hospital,  his  arm  had  improved, 
but  he  could  not  flex  his  fingers. 

Mrs.  G.,  £et.  70,  fell  down  a  flight  of  steps,  and  dislocated  her  arm 
into  the  axilla.  She  did  not  suspect  the  nature  of  the  injury,  and  no 
surgeon  was  called.  I  was  consulted  one  week  after  the  accident,  at 
which  time  she  was  suffering  great  pain  from  the  pressure  of  the  head 
of  the  bone  upon  the  axillary  nerves.  We  first  attempted  to  reduce 
the  bone  by  resting  the  knee  in  the  axilla  while  she  was  sitting,  but 
without  success.  We  then  placed  her  in  bed,  and  with  my  knee  in 
the  axilla,  the  acromion  process  being  supported  by  the  hands  of  an 
assistant,  we  restored  the  bone  after  a  few  moments  of  pretty  firm  ex- 


550  DISLOCATIONS    OF    THE    SHOULDER. 

tension  downwards  and  outwards.  After  the  reduction  she  could  not 
raise  her  arm,  but  the  pain  was  much  abated.  One  month  later,  the 
arm  remained  very  weak.  She  could  not  raise  it  more  than  six  inches 
toward  her  head,  but  I  could  raise  it  to  a  right  angle  with  the  body 
without  causing  pain.  The  whole  hand  felt  numb,  and  was  occasion- 
ally painful.  The  deltoid  muscle  was  slightly  atrophied.  There  was 
also  a  slight  flatness  under  the  acromion  process  behind,  and  on  the 
outer  side,  with  a  corresponding  fulness  in  front. 

Mary  Ann  Easier,  £et.  47,  was  admitted  to  the  hospital,  with  a  dis- 
location of  the  right  humerus  into  the  axilla.  The  arm  had  been 
dislocated  three  weeks,  in  consequence  of  a  fall  upon  the  upper  and 
outer  part  of  the  shoulder.  An  empiric,  who  saw  it  fifteen  minutes 
after  the  fall,  and  when  the  arm  was  not  swollen,  said  it  was  not  dis- 
located. On  the  fifth  day,  a  Catholic  clergyman  discovered  that  it 
was  out,  and  attempted  to  reduce  it,  but  was  not  successful.  When 
she  came  under  my  notice,  the  arm  was  lengthened  about  one-quarter 
or  one-half  of  an  inch,  and  hung  out  from  the  body  in  a  condition  of 
almost  complete  paralysis.  There  was  very  little  swelling  about  the 
shoulder  or  arm,  and  the  head  of  the  bone  could  be  distinctly  felt  in 
the  axilla.  The  patient  being  rendered  partially  insensible  by  chloro- 
form, I  placed  my  heel  in  the  axilla,  and  by  pulling  moderately  about 
thirty  seconds  in  a  direction  slightly  outwards  from  the  line  of  the 
body,  the  bone  was  reduced.  Seven  days  after  the  reduction,  she  left 
the  hospital,  the  arm  being  yet  quite  useless,  though  not  greatly 
swollen.  There  was  also  a  striking  fulness  in  front  of  the  head  of 
the  bone. 

Wra.  Gardner,  of  Painted  Post,  N.  Y.,  ast.  75,  dislocated  the  right 
humerus  into  the  axilla  twenty  years  before  I  saw  him,  by  falling 
upon  his  hands  with  his  arms  extended.  I  found  the  arm  weak  and 
atrophied,  so  that  he  could  raise  it  but  slightly  outwards  from  bis 
side ;  he  was  unable  to  move  it  forwards  much  beyond  the  line  of  bis 
body,  but  he  could  carry  it  back  quite  freely.  The  whole  hand  was 
in  a  condition  of  partial  insensibility. 

I  have  before  mentioned  the  case  of  Maria  Norrigan,  the  Swiss 
woman,  whose  arm  had  been  dislocated  downwards  seventeen  years. 
The  deltoid  muscle  has  become  greatly  wasted ;  the  head  of  the  bone 
can  be,  felt  obscurely  in  the  axilla  ;  the  arm  is  shortened  perceptibly  ; 
the  elbow  hangs  freely  against  the  side  ;  the  little  and  ring  fingers  are 
numb,  and  also  one-half  of  the  forearm ;  the  whole  hand  and  arm  are 
weak  and  atrophied  ;  she  complains  also  occasionally  of  a  troublesome 
sensation  of  formication  over  the  arm  and  hand  ;  she  cannot  straighten 
her  fingers  perfectly;  the  elbow  may  be  raised  from  the  side  to  a  right 
angle  with  the  body,  but  she  cannot  raise  it  herself  more  than  one 
foot ;  she  carries  h  back  a  little  more  freely  than  forwards. 

In  compound  dislocations,  the  prognosis  must  always  be  regarded 
as  exceedingly  grave.  In  the  only  example  which  has  come  under 
my  notice,  the  circumstances  attending  which  I  shall  hereafter  men- 
tion in  the  general  chapter  devoted  to  compound  dislocations,  the 
patient  died  from  sloughing  of  the  axillary  artery.  Mr.  Scott  has, 
however,  reported  a -case,  in  a  boy  fourteen  years  of  age,  who  recovered 


DISLOCATIOX    OF    THE    SHOULDER    DOWXWAEDS.       551 

rapidly  after  the  reduction  was  effected,  and  in  thirteen  months  his 
arm  was  nearly  as  useful  as  before.' 

Treatment. — The  principles  of  treatment  in  this  dislocation  are  very 
simple  and  easy  to  be  comprehended.  I  speak  now  of  recent  uncom- 
plicated cases  of  dislocation  into  the  axilla  ;  and,  notwithstanding  the 
various  and  sometimes  almost  contradictory  views  which  surgeons 
have  entertained  as  to  the  best  and  most  rationttl  modes  of  procedure, 
I  continue  to  affirm  that  the  laws  which  are  to  govern  the  reduction 
in  a  great  majority  of  cases  are  established  and  indisputable. 

Observe  now  the  obvious  anatomical  facts,  and  then  consider  the 
inevitable  inferences. 

The  capsule  is  torn,  generally  extensively,  along  the  inner  and 
lower  margins  of  the  socket.  The  head  of  the  bone  is  lodged  below 
and  slightly  in  advance  of  its  natural  position,  in  consequence  of 
which  the  points  of  origin  and  insertion  of  the  deltoid  muscle  and  the 
supra- spinatus  are  separated  somewhat  and  their  fibres  rendered  tense, 
insomuch  that  the  arm  is  abducted  and  actually  lengthened. 

At  first,  and  in  the  most  simple  cases,  these  are  the  only  muscles 
which  are  in  a  state  of  extreme  tension,  but  after  the  lapse  of  a  few 
hours,  or  of  a  few  days,  nearly  all  the  other  muscles  about  the  joint, 
most  of  which  were  originally  only  in  a  condition  of  moderate  exten- 
sion, and  some  of  which  were  rather  relaxed  than  extended,  sym- 
pathize with  those  which  are  suffering  the  most,  and  a  general  con- 
traction and  rigidity  ensue,  increased  also  at  the  last  by  the  superven- 
tion of  inflammation  and  its  consequences. 

What,  from  these  simple  premises,  must  be  the  obvious  practical 
deductions? 

That  in  the  simplest  forms  of  the  dislocation  the  most  rational  mode 
of  reduction  will  be  to  elevate  the  arm  sufficiently  to  relax  the  over- 
strained deltoid  and  supra-spinatus  muscles,  which  bind  the  head  of 
the  bone  in  its  new  position,  and  to  pull  gently  in  the  same  direction, 
in  order  to  overcome  the  moderate  resistance  offered  by  several  other 
muscles,  but  whose  tension  cannot  be  relieved  by  the  same  manoeuvre. 

Failing  in  this,  that  we  shall  increase  the  relaxation  of  the  first 
named  muscles,  by  pulling  at  a  right  angle  with  the  body,  or  even 
directly  upwards;  and  meanwhile,  as  we  carry  the  arm  more  and 
more  upwards,  we  shall  operate  more  powerfully  against  the  resistance 
of  the  other  muscles. 

If  in  all  these  modifications  of  the  same  procedure,  we  keep  the  arm 
a  little  back  of  the  axis  of  the  body,  we  shall  accomplish  the  indica- 
tions the  most  perfectly. 

Such  are  the  conclusions  which  must  be  drawn  from  the  anatomical, 
or,  as  Mr.  Pott  would  call  it,  the  "physiological,"  argument ;  and  which 
assumes  as  its  basis  that  the  muscles  constitute  the  sole  or  the  main 
obstacle  to  the  return  of  the  bone  to  its  socket.  If  any  surgeon  main- 
tains that  the  premise  is  unsound,  and  that  the  restoration  of  the  head 
of  the  bone  is  opposed  by  the  untorn  fibres  of  the  capsules  or  by  any 

'  Scott,  Amer.  .Jonrn.  of  Med.  Sci.,  vol.  xx.  p.  515,  Aug.  1837,  from  the  London 
Lancet  for  March  4,  1837. 


552  DISLOCATIONS    OF    THE    SHOULDER. 

Other  important  circumstance  than  the  action  of  the  muscles  (we  speak 
of  ordinary  cases),  we  shall  content  ourselves  by  referring  him  again 
to  the  extensive  laceration  which  this  capsule  generally  suffers,  and 
to  the  constrained  and  almost  uniform  position  of  the  arm,  as  a  sufB- 
cient  reply  to  his  objection. 

It  must  not  be  forgotten  that  in  all  these  modes  of  extension,  for 
■with  nearly  all  of  them  some  slight  degree  of  extension  is  found  neces- 
sary, there  must  be  afforded  some  point  of  resistance  beyond  the  bone ; 
and  this  it  is  really  which  has  constituted  one  of  the  greatest  impedi- 
ments to  reduction.  It  is  not  that  the  muscles  are  in  such  an  extra- 
ordinary state  of  extension  or  rigidity  that  they  must  be  operated 
against  with  great  force;  it  is  not  that  the  margin  of  the  glenoid  fossa 
is  an  elevated  barrier,  like  the  margin  of  the  acetabulum,  over  which 
the  bone  must  be  lifted  before  it  can  fall  into  its  socket ;  but  the  ex- 
planation of  the  difficulty  so  often  experienced  in  producing  effective 
extension  and  counter-extension  is  to  be  sought  for  mainly  in  the 
fact  that  the  scapula,  upon  which  the  humerus  rests,  is  movable,  being 
held  to  the  body  by  little  else  than  muscles,  which,  in  fact,  bind  the 
scapula  much  less  firmly  to  the  body  than  the  muscles  of  the  shoulder 
now  bind  the  scapula  to  the  arm ;  while  at  the  same  time  the  scapula, 
itself  presents  very  few  points  against  which  a  counter-extending  force, 
can  be  properly  and  efficiently  applied. 

Occasionally  it  will  be  only  necessary  to  elevate  the  arm  to  an  acute 
angle,  or  to  a  right  angle  with  the  body,  when,  the  resistance  of  the 
deltoid  and  supra-spinatus  being  overcome,  the  bone  will  at  once  re- 
sume its  place.  In  several  instances  which  have  come  under  my  notice 
nothing  more  has  been  necessary ;  and  where  it  can  be  done,  the  least 
possible  pain  and  injury  are  inflicted.  It  is  the  method,  therefore, 
which  in  all  recent  cases  I  have  first  tried  and  would  wish  to  recom- 
mend. By  it  I  have  more  than  once  succeeded  when  other  and  more 
violent  efforts  have  failed. 

At  other  times  it  will  be  necessary  to  add  to  this  simple  manipula- 
tion only  a  moderate  degree  of  extension,  such  as  the  hands  of  the 
surgeon  can  make,  without  the  application  of  direct  counter-extension 
except  what  is  effected  by  the  weight  and  resistance  of  the  body. 

If,  however,  the  bone  refuse  to  move,  we  shall  then  be  obliged  to 
consider  upon  what  point  and  by  what  means  we  can  best  apply  a 
counter-extending  force.  Ample  experience  has  taught  me  that  the 
extremity  of  the  acromion  process  is  the  only  available  point  when 
we  are  making  the  extension  in  a  line  below  a  right  angle,  or  in  a 
line  downwards  more  or  less  approaching  the  axis  of  the  body.  It 
has  been  supposed  that  the  counter-extension  could  be  made  in  the 
axilla  against  the  inferior  margin  of  the  scapula  ;  but  several  obstacles 
are  presented  to  the  successful  application  of  force  at  this  point.  The 
axillary  space  is  narrow  and  deep,  so  that  even  with  the  ingenious 
contrivance  of  placing  first  a  ball  of  yarn  in  the  axilla,  and  upon  this 
the  heel  of  the  operator,  it  will  be  found  exceedingly  difficult  to  enter 
the  axilla  without  at  the  same  time  pressing  with  considerable  force 
against  its  muscular  margins;  but  to  press  upon  the  pectoralis  major 
and  latissimus  dorsi  is  to  neutralize  our  own  efforts.     If,  however, 


DISLOCATIOX    OF    THE    HUMERUS    DOWNWARDS.         553 

the  heel  or  the  ball  does  press  fairly  into  the  axilla,  it  will  not  find 
the  scapula  readily,  but  it  must  impinge  first  upon  the  head  of  the 
liumerus,  which  is  always  a  little  to  the  inner  side  of  the  scapula.  If 
it  ever  is  made  to  reach  actually  the  inferior  border  of  the  scapula, 
and  I  do  not  think  it  is,  the  effect  must  be  still  only  to  tilt  the  scapula 
upon  itself  by  throwing  back  its  lower  angle,  and  not  to  separate  the 
glenoid  cavity  or  its  upper  and  anterior  margin  from  the  head  of  the 
humerus. 

Whatever  success,  therefore,  may  have  attended  this  mode  of  prac- 
tice, either  in  my  own  hands  or  in  the  hands  of  other  surgeons,  must 
be  ascribed  not  to  the  counter-extension  thus  effected,  but  simply  to 
the  operation  of  the  heel  as  a  wedge,  which,  by  insinuating  itself  be- 
tween the  body  and  the  head  of  the  bone,  has  thrust  it  outwards  and 
upwards  into  its  socket;  or  to  its  having  acted  as  a  fulcrum  upon 
which  the  humerus  has  operated  as  a  lever. 

It  is  to  the  extremity  of  the  acromion  process,  then,  that  we  must 
apply  our  counter-extension  when  we  are  employing  this  mode  of  ex- 
tension. The  fingers  or  hands  of  a  faithful  assistant  may  answer  the 
purpose,  or  having  removed  his  boot,  the  operator  may  often  press 
successfully  with  the  ball  of  his  foot,  and  the  more  he  carries  the  arm 
outwards  the  more  secure  will  be  his  seat  upon  the  process;  or  we 
may  adopt  some  of  the  contrivances  for  securing  the  process  which 
have  been  suggested  by  other  surgeons ;  such  as  a  band  crossing  the 
shoulder,  and  made  fast  to  a  counter-band,  which  passes  through  the 
armpit  and  against  the  side  of  the  body.  Dr.  Physick,  of  Philadelphia, 
reduced  a  dislocation  in  this  way  as  early  as  the  year  1790,  in  the 
case  of  a  patient  admitted  to  St.  George's  Hospital,  in  London,  while 
he  was  a  student  of  medicine,  and  he  subsequently  taught  the  same 
in  his  lectures.  Physick  directed  that  an  assistant  should  press  firmly 
against  the  process  with  the  palm  of  his  hand.  Dorsey  and  Hays  ap- 
prove of  the  same  method,^  and  perhaps  a  majority  of  American  sur- 
geons regarded  it  favorably. 

If  we  pull  directly  outwards,  at  a  right  angle  with  the  body,  we 
may  still  continue  to  press  upon  the  acromion  process  with  the  foot; 
or  we  may  perhaps  trust  to  the  method  of  making  counter-extension 
first  suggested  by  Nathan  Smith,  of  New  Haven,  and  subsequently 
recommended  by  his  son,  Prof  Nathan  E.  Smith,  of  Baltimore.  Says 
Prof.  N.  P.  Smith  :-  "  What  surgeon  of  experience  has  not  encountered 
the  difficulty  wliich  almost  always  occurs  in  fixing  the  scapula?"  and 
he  then  proceeds  to  give  what  seems  to  him  the  most  effectual  mode 
of  rendering  the  scapula  immovable,  namel}'-,  to  make  the  counter- 
extension  from  the  opposite  wrist.  By  this  method  the  trapezii  are 
provoked  to  contraction,  and  the  scapula  of  the  injured  side  is  drawn 
firmly  toward  the  spine  and  the  opposite  scapula.  In  illustration  of 
the  value  of  this  procedure  he  relates  the  case  of  a  gentleman  who 

1  Phj-sick,  Amer.  Journ.  Med.  Sci.,  vol.  xix.  p.  386,  Feb.  1837.  Dorsey's  Ele- 
ments of  Surgery,  vol.  i.  p.  214.     Philadelphia,  1813. 

2  Smith's  Med.  and  Surir.  Memoirs,  Baltimore,  1831,  p.  337;  also,  Amer.  Journ. 
Med.  Sci.,  July,  18G1 ;  also^  American  Med.  Times,  Nov.  9,  1801 ;  paper  by  Stephen 
Rogers,  M.D. 


5oi 


DISLOCATIONS    OF    THE    SHOULDEE, 


had  suffered  a  dislocation  of  his  left  shoulder,  and  upon  whom  an 
unsuccessful  attempt  at  reduction  had  already  been  made  by  a  re- 
spectable surgeon.  Dr.  Smith  being  called,  proceeded  as  follows: 
Two  gentlemen  made  counter-extension  from  the  opposite  wrist,  while 


K.  R.  Smith's  method. 

Dr.  Smith  and  Dr.  Knapp  made  extension  from  the  wrist  of  the  injured 
side,  at  first  pulling  it  downwards,  but  gradually  raising  it  to  the 
horizontal  direction,  and  then  gently  depressing  the  wrist.  On  the 
effort  being  steadily  continued  for  two  or  three  minutes,  the  bone 
was  observed  to  slip  easily  into  its  place. 

But  no  position  places  the  scapula  so  completely  under  our  control 
as  that  in  which  the  arm  is  carried  almost  directly  upwards  and  the 
foot  is  placed  upon  the  top  of  the  scapula.  By  this  method  we  may 
succeed  generally  when  every  other  expedient  has  failed,  yet  it  is 
painful,  and  I  cannot  but  think  that  it  increases  the  laceration  of  the 
capsule,  and  does  sometimes  serious  injury  to  the  muscles  about  the 
joint.  La  Mothe  was  the  first  to  recommend  this  method,^  but  as 
early  as  the  year  1764,  Charles  White,  of  Manchester,  made  fast  a  set 
of  pulleys  in  the  ceiling,  and,  placing  a  band  around  the  wrist  of  the 
dislocated  arm,  he  drew  the  patient  up  until  the  whole  body  was  sus- 

'  La  Motlie,  Amer.  Jonrn.  Med.  Sci.,  vol.  xix.  p.  387,  Nov.  1836,  from  Melanges 
de  Med.  et  Chir.,  Paris,  1813. 


DISLOCATION    OF    THE    HUMERUS    DOWNWARDS. 


555 


pended.  No  pressure,  however,  was  made  upon  the  scapula  from 
above,  which  is  no  doubt  the  most  essential  part  of  the  process.^  By 
La  Mothe's  plan,  Jobert  succeeded  after  twenty-three  days  when  all 
the  usual  methods  had  failed.^  Sometimes  this  procedure  is  modified 
by  placing  the  hand  of  the  operator  against  the  top  of  the  scapula,  as 
is  shown  in  the  accompanying  drawing  (Fig.  240);  and  I  have  several 
times  succeeded  in  this  way  after  other  measures  have  failed. 

Ficr.  240. 


La  JIothe"s  method,  modified 

A  gentle  movement  backwards  or  forwards,  a  slight  rotation  of  the 
limb,  or  suddenly  dropping  the  arm  toward  the  body,  diverting  the 
attention  of  the  patient,  are  little  tricks  of  the  operator,  which  now 
and  then  prove  successful. 

Sir  Astley  Cooper  thus  describes  his  method  of  applying  the  heel 
to  the  axilla  (Fig.  241) : — 

Fig.  241. 


Sir  Aetley  Cooper's  method  of  applying  extension  with  the  heel  in  the  axilla. 

'  C.  White,  Amer.  Jouni.  Med.  Sci.,  Nov.  1836,  from  Med.  Obs.  and  Inquiries, 
vol.  ii.  p.  273,  London,  17G4. 
2  Ibid.,  vol.  xxiii.  p.  237,  Nov.  1838. 


556 


DISLOCATIONS    OF    THE    SHOULDER. 


"  The  patient  should  be  phiced  in  the  recumbent  posture  upon  a 
table  or  sofa,  near  to  the  edge  of  which  he  is  to  be  brought;  the  sur- 
geon then  binds  a  wetted  roller  around  the  arm  immediately  above 
the  elbow,  upon  which  he  ties  a  handkerchief;  then  he  separates  the 
patient's  elbow  from  his  side,  and,  with  one  foot  resting  upon  the 
floor,  he  places  the  heel  of  his  other  foot  in  the  axilla,  receiving  the 
head  of  the  os  humeri  upon  it,  whilst  he  is  himself  in  the  sitting  pos- 
ture by  the  patient's  side.  He  then  draws  the  arm  by  means  of  the 
handkerchief,  steadily,  for  three  or  four  minutes,  when,  under  common 
circumstances,  the  head  of  the  bone  is  easily  replaced;  but  if  more 
force  be  required,  the  handkerchief  may  be  changed  for  a  long  towel, 
by  which  several  persons  may  pull,  the  surgeon's  heel  still  remaining 

in  the  axilla.  I  generally  bend  the 
forearm  nearly  at  right  angles  with 
the  OS  humeri,  because  it  relaxes  the 
biceps,  and  consequently  diminishes 
its  resistance." 

He  was  also  accustomed  in  some 
cases  to  reduce  the  dislocation  by 
substituting  the  knee  for  the  heel. 
Placing  tiie  patient  upon  a  low  chair, 
the  axilla  is  laid  over  the  knee  of  the 
operator,  and  while  one  hand  steadies 
the  acromion  process  and  scapula,  the 
other  presses  downwards  upon  the 
lower  end  of  the  humerus  (Fig.  242). 
If  some  hours  or  days  have  elapsed 
since  the  occurrence  of  the  dislocation, 
it  will  be  necessary  to  resort  to 
chloroform  or  ether  for  the  purpose 
of  paralyzing  the  muscles,  as  well  as 
with  the  view  of  preventing  pain,  and 
it  may  be  necessary,  in  addition,  to 
resort  to  pulleys,  or  to  some  similar 
permanent  mode  of  extension.  The 
same  measures  also  sometimes  become  necessary  in  very  recent  cases, 
especially  in  muscular  subjects. 

In  employing  the  pulleys  we  generally  operate  not  exactly  in  a 
line  with  the  axis  of  the  body,  nor  at  more  than  a  right  angle,  but 
between  an  angle  of  45°  and  a  right  angle. 

Mr.  Skey  has  suggested  a  plan  by  which  we  may  combine  the 
principle  of  the  heel  in  the  axilla  with  the  pulleys,  but  which  plan 
would,  in  my  judgment,  be  very  much  improved  by  a  counter- 
extending  force  applied  to  the  acromion  process.  I  ought  to  say, 
however,  that  Mr.  Skey  prefers  that  the  scapula  should  not  be  fixed, 
believing  that  the  reduction  is  much  more  easily  effected  when  the 
glenoid  cavity  is  drawn  downwards  in  the  act  of  making  the  exten- 
sion. 

With  all  respect  for  the  opinion  of  this  distinguished  surgeon,  we 
cannot  precisely  agree  with  him,  and  while  we  would  be  disposed  to 


Sir  Astley  Cooper's   method   of  operating 
with  the  knee  in  the  axilla. 


DISLOCATION    OF    THE    HUMERUS    DOWNWARDS.         557 

recommend  in  some  cases  a  trial  of  his  method  of  applying  the  pul- 
leys, we  would  at  the  same  time,  or  certainly  in  the  event  of  its  failure, 
add  the  acromial  support,  and  especially  would  we  advise  that  the 
arm  should  be  more  abducted.  The  following  is  Mr.  Skey's  method, 
as  described  by  himself: — 

"There  is  no  reason  why,  in   very  muscular   subjects,  or  in  old 
dislocations,  the  same  principle  may  not  be  applied  conjointly  with 

Fig;.  243. 


Iron  knob  employed  by  Skey,  instead  of  the  heel. 

the  use  of  pulleys.  For  the  purpose  of  retaining  this  admirable, 
because  most  efficient  principle,  I  employ  a  well-padded  iron  knob, 
which  may  represent  the  heel,  from  which  there  extend  laterally  two 
strong  straight  branches  of  the  same  metal,  each  ending  in  a  bulb 
or  ring  of  about  four  inches  in  length,  the  office  of  which  is  designed 
to  keep  the  margins  of  the  axilla  as  free  from  pressure  as  possible." 
The  iron  knob  is  to  be  pressed  well  up  into  the  axilla  and  attached  to 
cords  fastened  to  a  staple;  the  patient  lying  upon  his  back  or  inclined 
a  little  to  the  opposite  side.  The  arm  is  then  to  be  drawn  downwards 
by  the  pulleys,  "as  nearly  as  possible  parallel  to,  and  in  contact  with, 
the  body."^ 

In  this  way  Mr.  Skey  says  that  he  has  succeeded  in  reducing  a 
great  many  dislocations,  whether  occurring  in  very  muscular  men,  or 
after  some  days',  or  weeks',  or  even  months'  duration  ;  and  he  thinks 
the  plan  especially  applicable  to  cases  which  require  long  and  per- 
sistent extension. 

Fie;.  244. 


Skey's  method  of  making  extension  and  counter-extension  witli  pulleys. 

Mr.  Skey  and  many  other  surgeons  prefer  to  make  the  extension 
from  the  hand.     I  have  succeeded  as  well,  and  it  has  seemed  to  bo 


'  Skey,  Operative  Surgery,  Amer.  ed.,  p.  93. 


558 


DISLOCATIONS    OF    THE    SHOULDER. 


less  painful  to  my  patients,  when  I  have  followed  the  practice  of  Sir 
Astley,  and  made  the  extension  from  the  arm.  Sir  Astlej  always 
made  the  extension  more  or  less  out  from  the  line  of  the  body,  and 
generally  almost  at  a  right  angle  when  using  the  pulleys,  the  scapula 
being  made  fast  by  "  a  girt  buckled  on  the  top  of  the  acromion,"  or  by 
a  split  cloth  (Fig.  245). 

Fig.  245. 


Sir  .'^stley  Cooper's  mode  of  making  extension  with  pulleys. 

The  instrument  invented  by  Dr.  Jarvis,  of  Portland,  Conn.,  called  the 
adjuster,  useless  and  even  mischievous  as  we  have  found  it  in  its  appli- 
cation to  the  treatment  of  fractures,  possesses  considerable  merit  as  an 
apparatus  for  reducing  old  dislocations,  especially  of  the  shoulder.  The 
principal  advantage  which  may  be  claimed  for  it  is,  that  while  the  forces 
are  being  applied  the  limb  may  be  moved  pretty  freely  in  all  direc- 
tions; thus  enabling  us  to  employ  rotation  at  the  same  time  that  the 
extension  is  made.  We  may  also  lift  or  depress,  adduct  or  abduct 
the  limb  without  relaxing  the  extension.  In  the  hands  of  American 
surgeons  it  has  occasionally  been  successful  when  other  means  have 
failed.  Dr.  Jarvis  has  related  a  case  presented  at  the  Marine  Hos- 
pital, at  Mobile,  Tenn.,  of  forty-two  days'  standing,  which  he  reduced 
on  the  second  attempt,  after  other  means  had  failed  ;^  and  Dr.  May,  of 
AVashington,  reduced  a  similar  dislocation  at  the  end  of  six  weeks, 
by  the  same  apparatus,  without,  however,  having  previously  resorted 
to  any  other  means.^ 

I  have  myself  used  the  apparatus  occasionally,  both  in  my  hospital 
and  private  practice,  and  can  speak  favorably  of  its  operation. 

I  must  not  omit  to  mention  the  practice  adopted  by  Prof.  H.  H. 
Smith,  of  Philadelphia,  according  to  whom  nearly  all  dislocations  of 
the  shoulder,  of  a  recent  date,  may  be  promptly  and  easily  reduced 

'  Boston  Med.  and  Surg.  Journ.,  vol.  xxxix.  p.  215. 
2  Boston  Med.  and  Surg.  Journ.,  vol.  xxxv.  p.  454. 


DISLOCATION    OF    THE    HUMERUS    DOWNWARDS.         559 

by  manipulation  alone.  His  method  consists,  first,  in  flexing  the  fore- 
arm upon  the  arm,  while,  at  the  same  moment,  the  elbow  is  lifted  from 
the  body;  second,  in  rotating  the  humerus  upwards  and  outwards, 
employing  the  forearm  as  a  lever;  and  third,  in  reversing  this  last 
movement,  that  is,  rotating  the  humerus  downwards  and  inwards  while 
at  the  same  moment  the  elbow  is  carried  again  to  the  side.* 

When  the  dislocation  is  into  the  axilla,  this  manoeuvre  will  generally 
succeed;  but  if  the  head  of  the  humerus  has  slipped  forwards,  even 
onh^  sufficient  to  engage  itself  slightly  under  the  tendons  of  the 
coraco-brachialis  and  biceps,  the  outward  rotation  of  the  humerus 
will  inevitably  thrust  the  head  further  forward,  and  fasten  it  more 
certainly  underneath  these  tendons ;  while  the  rotation  of  the  humerus 
in  the  opposite  direction  will  alone  often  be  sufficient  to  carry  the 
head  directly  into  the  socket. 

Ancient  Luxations. — Finally,  I  ought  to  speak  somewhat  more  in 
detail  of  the  manner  of  procedure  and  of  the  principles  involved  in 
the  reduction  of  old  dislocations,  or  of  dislocations  requiring  the  inter- 
position of  mechanical  appliances;  especially  with  a  view  to  the  more 
complete  exposition  of  my  own  practice  in  these  cases. 

If  the  dislocation  is  recent,  but  reduction  is  found  impossible  with- 
out the  aid  of  mechanical  apparatus,  the  difficulty  will  be  understood 
to  consist  mainly,  if  not  altogether,  in  the  resistance  offered  by  the 
muscles.  If,  in  a  few  exceptional  cases,  the  capsule,  or  an  untorn 
tendon,  or  the  margin  of  the  glenoid  fossa,  present  themselves  as 
obstacles,  they  must  still  be  considered  as  unusual  and  extraordinary 
impediments,  the  existence  of  which  may  be  regarded  rather  as  pos- 
sible than  probable. 

Almost  our  sole  purpose,  then,  it  will  be  understood,  in  all  recent 
cases  requiring  mechanical  appliances,  and  in  some  ancient  cases,  is  to 
overcome  the  contraction  of  the  muscles. 

We  prefer  always  to  place  the  patient  upon  a  mattress  laid  upon 
the  floor;  two  silk  handkerchiefs,  or  two  pieces  of  a  cotton  roller,  are 
then  laid  along  the  radial  and  ulnar  sides  of  the  humerus,  and  over 
the  middle  of  these,  immediately  above  the  condyles,  a  wetted  roller 
is  applied,  its  end  being  made  fast  with  a  needle  and  thread  rather 
than  with  a  pin.  The  upper  ends  of  the  longitudinal  strips,  or  of  the 
handkerchiefs,  are  now  turned  down  and  tied  to  the  opposite  ends, 
thus  converting  them  both  into  lateral  loops.  For  the  purpose  of 
making  counter-extension,  a  sheet  is  passed  around  the  body  under 
the  axilla,  and  made  fast  to  a  staple ;  while  an  intelligent  assistant  is 
to  manage  the  scapula  with  his  naked  hands,  either  by  pulling  with 
his  fingers  placed  under  the  process,  or  by  pushing  with  the  palm  of 
his  hand  and  ball  of  his  thumb.  The  pulleys,  secured  to  a  staple 
exactly  opposite  to  that  which  holds  the  counter-extending  band,  are 
made  ready,  but  not  for  the  present  attached  to  the  arm. 

As  soon  as  the  patient  is  placed  completely  under  the  influence  of 
an  anaesthetic,  the  operator  is  ready  to  proceed  with  the  reduction. 
It  is  my  maxim  never  to  attempt  to  accomplish  by  complicated  and 

'  H.  H.  Smith,  Gross's  Surg.,  ed.  of  1863,  p.  153. 


560  DISLOCATIONS    OF    THE    SHOULDER. 

violent  measures  what  may  be  done  as  well  by  more  simple  and 
gentle  means.  I  think  it  proper,  therefore,  to  make  several  attempts 
at  reduction  by  manipulation  alone,  aided  now  by  the  anaesthetic,  the 
extending  and  counter-extending  bauds,  &c.,  before  resorting  to  the 
pulleys.  Seating  himself  upon  the  mattress,  with  his  boots  drawn,  the 
surgeon  should  bend  the  forearm  to  a  right  angle  with  the  arm,  and 
planting  one  heel  in  the  axilla,  with  one  hand  he  should  seize  upon 
the  loops  at  the  elbow,  and  with  the  other  steady  the  hand  and  fore- 
arm of  the  patient,  while  he  proceeds  to  make  firm  traction  for  a  few 
seconds  in  the  line  of  the  body,  or  only  a  little  out  from  this  line. 
Failing  in  this,  he  may  direct  the  assistant  to  seize  upon  the  scapula, 
and  make  counter-extension;  still  not  succeeding,  he  may  change  his 
foot  from  the  axilla  to  the  acromion  process  and  pull  directly  outwards 
at  a  right  angle  with  the  body,  or  he  may  swing  himself  gradually 
around  until  he  comes  to  be  above  the  head  of  .the  patient,  and  the 
foot  presses  firmly  upon  the  top  of  the  scapula;  now  descending  again 
in  the  same  direction,  he  will  very  probably  find  the  limb  reduced,  or 
capable  of  being  reduced  easily,  by  operating  upon  it  as  a  lever  by 
laying  it  across  the  body  while  at  the  same  moment  it  is  rotated 
slightly  inwards. 

If  still  the  reduction  is  not  accomplished,  the  pulleys  must  at  once 
be  put  in  requisition.  The  sheet  passed  around  the  chest  and  fastened 
to  a  staple,  is  only  a  means  of  supporting  the  body  and  rendering  it 
more  steady ;  as  a  means  of  counter-extension  its  value  is  inconsider- 
able. To  make  fast  the  scapula,  we  must  still  rely  mainly  upon  the 
naked  hands  of  strong  men,  or  upon  a  strap  drawn  firmly  across  the 
process  and  held  in  place  by  an  assistant. 

Whenever  we  employ  extension  without  the  aid  of  antesthetics,  as 
sometimes  we  are  compelled  to  do,  it  must  be  constantly  borne  in 
mind  that  it  is  proposed  to  conquer  the  muscles  by  fatiguing  them, 
and  that  this  cannot  be  done  by  a  force  suddenly  applied,  however 
great  it  may  be,  but  only  by  gentle,  steady,  and  long-continued  exten- 
sion. The  muscles,  when  attacked  openly  and  vigorously,  resist,  and 
will  suffer  laceration  rather  than  yield,  while,  on  the  other  hand,  an 
insidious  but  persevering  approach  seldom  fails  to  end  in  their  defeat. 
The  same  is  true,  but  in  a  much  less  degree,  when  the  patient  is  in- 
sensible from  ansesthesia. 

The  forearm  is  again  flexed,  and  the  arm  carried  out  to  a  right 
angle  with  the  body,  the  pulleys  secured  to  the  loops,  and  the  assistant 
takes  hold  upon  the  process,  while  the  surgeon  draws  gently  upon  the 
rope  attached  to  the  pulleys;  as  soon  as  everything  is  moderately 
tense,  he  is  to  desist  for  a  few  moments.  Again  the  rope  is  drawn 
upon  gently,  and  again  the  progress  of  the  extension  is  suspended. 
In  this  way  the  operator  is  to  proceed  during  half  an  hour,  or  two 
hours,  as  the  nature  of  the  case  may  demand  ;  occasionally  rotating 
the  humerus,  and  occasionally  lifting  its  head  toward  the  socket. 
Meanwhile,  it  is  understood  that  the  principal  counter-extension  is 
made  by  the  assistants,  who  must  relieve  each  other,  at  the  acromion 
process.  The  sheet  in  the  axilla,  or  rather  against  the  side  of  the 
chest,  has  some  value  in  this  respect  when  the  arm  is  at  a  right  angle 


DISLOCATION    OF    THE    HUMERUS    DOWNWARDS.         561 

with  the  body,  but  in  itself  it  cannot  control  the  scapula,,  only  as  it 
holds  the  body  to  which  the  scapula  is  attached.  Much,  therefore,  as 
we  may  regret  the  inconvenience  of  making  counter-extension  by 
hands  alone,  experience  and  anatomy  alike  must  teach  that  here  it  is 
the  only  mode.  If  these  dislocations  are  reduced  often  by  other 
methods,  as  no  doubt  they  are,  then  it  is  only  an  evidence  that  in 
these  examples  little  or  no  counter-extension  was  necessary. 

Sometimes  the  dislocation  is  not  reduced  when  the  extension  is 
given  up,  but  if  then  a  resort  is  promptly  made  to  some  one  of  the 
simple  methods  already  described,  while  the  muscles  are  still  ex- 
hausted, it  very  often  happens  that  the  reduction  is  easily  accom- 
plished. 

It  will  be  prudent  in  all  cases,  in  order  to  prevent  a  reluxation, 
whether  the  dislocation  is  recent  or  ancient,  as  soon  as  its  reduction 
is  effected,  to  place  the  arm  in  a  sling  and  secure  the  elbow  to  the  side 
by  a  few  turns  of  a  roller.  I  do  not  think  the  axillary  pad  necessary, 
and  I  am  afraid  it  has  sometimes  done  as  much  mischief  as  the  dislo- 
cation itself. 

The  following  example  will  illustrate  the  variety  of  expedients  to 
which  we  are  obliged  sometimes  to  resort  before  our  efforts  prove 
successful. : — 

Thomas  Leeding,  of  Niagara  Co.,  N".  Y.,  get.  52,  a  laborer,  and  a 
muscular  man,  dislocated  his  right  arm  into  the  axilla,  by  jumping 
from  the  cars  when  they  were  in  full  motion.  The  blow  was  received 
upon  the  shoulder.  An  intelligent  country  surgeon,  assisted  by 
several  other  persons,  attempted  reduction  within  an  hour  after  the 
accident,  but  failed,  and  as  the  patient  had  some  distance  to  travel,  he 
was  not  brought  under  my  notice  until  eighteen  hours  had  elapsed. 
We  first  administered  chloroform,  and  then,  while  an  assistant  held 
firmly  upon  the  acromion  process,  I  pulled  in  the  line  of  the  body, 
then  outwards,  and  finally  upwards,  but  to  no  purpose.  Having  then 
applied  Jarvis's  "adjuster,"  and  after  the  arm  had  been  kept  extended 
at  a  right  angle  with  the  body  fifteen  minutes,  we  removed  the  appa- 
ratus, and  found  the  bone  in  its  place. 

John  Harrington,  get.  50,  a  very  large  and  powerful  man,  fell  while 
intoxicated,  and  dislocated  his  lelt  humerus  into  the  axilla.  No  sur- 
geon was  called  until  the  tenth  day,  when  he  first  consulted  Dr.  Dud- 
ley, who  at  once  brought  him  to  me.  Without  delay  we  applied  the 
pulleys,  and  placing  the  arm  at  a  right  angle  with  the  body,  we  made 
extension  fifteen  minutes;  occasionally  also  rotating  the  arm.  We 
then  removed  the  pulleys,  and  while  an  assistant  held  upon  the  acro- 
mion process,  with  my  heel  in  the  axilla,  I  made  extension  in  the  line 
of  the  axis  of  the  body,  then  outwards,  and  finally  upwards  with  my 
foot  upon  the  top  of  the  scapula.  I  next  seated  m^'-  patient  in  a  chair, 
and  drew  his  arm  and  axilla  forcibly  over  my  knee.  The  bone  was 
not  yet  reduced ;  I  therefore  bled  him  twenty-four  ounces,  or  until 
parljial  syncope  was  induced,  and  proceeded  to  repeat  most  of  these 
processes,  but  with  no  better  result.  At  this  moment  I  determined 
to  use  sulphuric  ether,  which  had  just  been  introduced  as  an  anaesthetic, 
and  while  he  was  completely  under  its  influence  the  pulleys  were  again 


562  DISLOCATIONS    OF    THE    SHOULDEK. 

applied,  and  the  extension  continued  for  some  time,  and  until  the  rope 
broke.  He  was  then  again  placed  in  a  chair,  and  the  axilla  brought 
over  my  knee,  when  in  a  moment  the  reduction  was  accomplished. 

John  Bowles,  of  Buffalo,  aged  45  years,  an  Irish  laborer,  tolerably 
muscular,  but  spare.  Bowles  fell  down  a  flight  of  stairs,  and  dislo- 
cated his  left  humerus  into  the  axilla.  The  shoulder  became  much 
swollen,  and  was  very  painful,  but  he  did  not  suspect  a  dislocation 
and  did  not  consult  "a  surgeon.  Eight  weeks  after  the  accident  he 
applied  to  me.  There  were  present  the  usual  signs  of  this  dislocation, 
but  the  arm  was  by  careful  measurement  one  inch  and  a  half  longer 
than  the  other. 

The  reduction  was  accomplished  on  the  same  day,  in  presence  of 
Drs.  Lee,  Webster,  Coventry,  Ford,  and  Jewett.  The  time  occupied 
in  the  reduction  was  about  two  hours.  An  attempt  was  first  made 
with  the  heel  in  the  axilla  and  with  violent  rotation  and  extension. 
The  same  plan  was  repeated  with  the  aid  of  ether,  which  was  adminis- 
tered freely.  Jarvis's  adjuster  was  now  applied,  with  no  result,  except 
that,  either  in  consequence  of  the  force  employed  by  the  adjuster,  or  in 
consequence  of  the  free  use  of  ether,  or  of  both,  he  became  convulsed 
violently,  which  was  accompanied  by  frothing  at  the  mouth  and  other 
grave  symptoms.  The  adjuster  was  removed,  and -the  exhibition  of 
ether  discontinued.  As  soon  as  the  convulsions  ceased,  and  before 
consciousness  had  returned,  extension,  rotation,  &c.,  were  again  made 
by  hands.  Finally,  after  all  extension  was  relinquished,  placing  my 
knee  in  the  axilla,  I  reduced  the  bone  by  a  very  slight  rotary  action 
upon  the  arm;  the  bone  was  at  once  plainly  in  its  socket,  but  the 
unusual  lensfth  of  the  limb  continued,  beins:  one  inch  and  a  half 
longer,  though  it  could  be  shortened  to  the  same  length  as  the  other 
by  lifting  the  elbow.  A  pad  was  placed  in  the  axilla,  and  the  arm 
secured  with  a  sling  and  roller.  The  next  day  the  arm  remained  in 
place,  but  it  was  now  only  one  inch  longer  than  the  other.  At  the 
end  of  a  fortnight  it  was  only  three-quarters  of  an  inch  longer,  and 
could  be  reduced  to  the  same  length  by  lifting;  the  pain  and  swelling 
about  the  shoulder,  which  never  were  great,  were  subsiding,  and  the 
patient  was  dismissed. 

However  skilfully  our  efforts  may  be  directed,  they  will  be  found 
occasionally  to  fail ;  either  owing  to  adhesions  which  have  taken  place 
between  the  head  of  the  bone,  or  rather  its  capsule,  and  the  adjacent 
tendons,  muscles,  etc.,  to  some  extraordinary  position  of  the  head  and 
neck  of  the  bone  in  its  relation  to  ligamentous  or  tendinous  structures, 
to  a  filling  up  of  the  glenoid  fossa,  or  to  some  other  cause  not  fully 
explained.  Such  failures  have  happened  not  only  in  the  hands  of 
ignorant  and  unskilful  surgeons,  destitute  of  appliances,  but  also  in  the 
hands  of  those  who  are  the  most  expert,  and  who  are  the  most  com- 
pletely provided  with  all  the  necessary  apparatus.  Indeed,  if  the  truth 
were  known,  it  would  probably  be  found  that  the  number  of  failures 
has  been  greater  than  the  successes.  The  records  of  surgery,  however, 
furnish  a  great  many  examples  of  ancient  dislocations  of  the  humerus 
reduced  after  periods  ranging  from  one  month  to  six,  or  even  longer. 
Dieffenbach  has  been  able  to  accomplish  the  reduction  of  a  forward 


DISLOCATIOX    OF    THE    HUMEEUS    DOWNWAEDS.         563 

dislocation  after  two  years,  but  not  until  he  bad  cut  tbe  tendons  of 
the  pectoralis  major,  latissimus  dorsi,  teres  major,  and  teres  minor,  and 
bad  divided  the  ligaments  surrounding  the  new  joint.^ 

It  would  be  unjust  to  the  young  surgeon  not  to  call  especial  atten- 
tion to  the  numerous  examples  of  serious  and  even  fatal  accidents 
which  have  followed  upon  the  attempts  to  reduce  ancient  luxations  at 
this  joint.  The  late  George  C.  Blackman,  of  Cincinnati,  a  distin- 
guished surgeon,  having  met  with  one  of  these  unfortunate  accidents 
in  his  own  practice,  has  had  the  candor  to  make  a  public  statement  of 
the  case  and  of  the  circumstances  which  attended  it.  In  a  letter  to 
the  editor  of  theWeslei-n  Lancet,  published  in  the  November  number 
for  1856,  he  writes  as  follows : — 

"  About  the  iOth  ult.,  aided  by  yourself,  I  succeeded  in  reducing  by 
manipulation,  without  the  pulleys,  a  dislocation  into  the  axilla,  of 
eighty  days'  standing.  The  reduction  was  accomplished  in  a  very  few 
minutes,  under  the  influence  of  chloroform  and  ether,  and  the  next 
morning  the  patient  left  for  the  country,  in  a  comfortable  condition. 
Since  that  I  have  received  no  tidings  from  him.  Encouraged  by  the 
result  in  this  case,  another  patient,  himself  a  ph3^sician,  a  tall,  athletic 
man,  and  about  fifty  years  of  age,  decided  to  submit  to  the  same  mani- 
pulation, although  his  arm  had  been  dislocated  for  about  sixteen  weeks. 
The  dislocation  was  downwards  and  inwards,  and  about  the  tenth  week 
an  unsuccessful  attempt,  by  another  surgeon,  had  been  made  with  the 
pulleys,  to  which  the  force  of  six  men  was  applied  for  two  and  a  half 
hours.  The  patient  being  under  the  influence  of  chloroform  and  ether, 
aided  by  yourself,  Drs.  Fries,  Gary,  Graham,  and  Kauffnian,  I  com- 
menced my  manipulations,  adducting,  rotating,  abducting,  and  elevat- 
ing the  arm.  These  efforts  had  been  made  for  about  ten  minutes,  and 
the  least  possible  violence  employed,  when  a  tumefaction  appeared  in 
the  pectoral  region,  which  in  a  few  minutes  attained  a  considerable 
size.  Supposing  that  the  axillary  artery  was  ruptured,  as  no  pulse 
could  be  felt  at  the  wrist,  a  ligature  was  immediately  applied  to  the 
vessel  at  the  upper  part  of  its  course.  The  operation  was  performed 
about  10  o'clock  A,M.,  and  compression  of  the  pectoral  region  made 
by  means  of  a  sponge  and  broad  roller.  On  removing  this  the  next 
morning,  the  tumefaction  had  nearly  disappeared.  The  patient  con- 
tinued comfortable,  and  about  nine  days  after  the  application  of  the 
ligature  I  was  compelled  to  leave  the  city  on  a  professional  visit  to 
Indiana,  I  left  on  Friday  afternoon  and  returned  on  Monday  morning, 
at  which  time  I  learned  that  my  patient  had  died  on  Sunday  morning, 
from  hemorrhage  at  the  seat  of  ligature," 

The  following  is  a  resumt  of  similar  accidents  which  have  from 
time  to  time  occurred  in  the  practice  of  other  surgeons. 

Desault  twice  observed,  after  attempts  to  reduce  old  luxations  of  the 
shoulder,  "tumeurs  aeriennesy  It  is  quite  probable,  however,  that  in 
each  case  the  tumor  was  caused  by  the  rupture  of  a  bloodvessel.^ 

Pelletan,  also,  attempting  to  reduce  a  luxation  of  four  months'  stand- 

'  Dieffeubacli,  Bost.  Med.  aud  Surg.  Journ.,  vol.  xxii.  p.  383,  from.  Mediciu. 
Zeitviiiu;. 
2  Desault,  Journ.  de  Cliir.,  t.  iv.  p.  301, 


564:  DISLOCATIONS    OF    THE    SHOULDER. 

ing,  thonglit  he  produced  a  tumeur  aerienne,  but  it  being  opened  the 
patient  bled  to  death.' 

Malgaigne,  attempting  to  reduce  a  dislocation  of  sixty-eight  days' 
standing,  was  surprised  by  a  sudden  tumefaction  in  the  axiHa,  and  on 
the  shoulder,  which  caused  so  much  alarm  as  to  induce  him  to  discon- 
tinue his  efforts.  Ice  was  applied,  and  the  hemorrhage,  which  he 
thought  came  from  muscular  branches,  was  arrested ^  Verduc  saw 
the  axillary  artery  ruptured  in  the  same  manner,  in  consequence  of 
which  the  patient  died.^  J.  L.  Petit  met  with  a  similar  case.  Platner 
mentions  a  case  of  rupture  of  both  axillary  artery  and  vein.  C.  Bell 
reports  an  example  of  rupture  of  the  artery  with  extensive  laceration 
of  the  muscles,  and  which  demanded  immediate  amputation,  Delpech 
ruDtured  the  artery,  and  his  patient  died  immediately.*  Flaubert  was 
more  fortunate,  the  effused  blood  being  absorbed  after  a  few  days. 
■  Froriep  saw  his  patient  die  within  one  hour  and  a  half  after  a  rupture 
of  the  axillary  vein.  John  C.  Warren,  of  Boston,  tied  the  subclavian 
artery  to  arrest  the  progress  of  an  enormous  aneurismal  tumor  in  the 
axilla,  caused  by  the  reduction  of  a  recent  dislocation.^  Gibson,  of 
Philadelphia,  lost  two  patients  in  attempting  to  reduce  old  luxations 
of  the  humerus,^  and  he  relates  another  fatal  case  occurring  in  the 
practice  of  David,  of  Eouen.  Leudet,  of  Rouen,  lost  a  patient  in  this 
way  in  1824.  In  this  latter  case,  and  in  both  the  cases  occurring  in 
the  practice  of  Gibson,  there  was  a  fracture,  also,  of  the  lower  margin 
of  the  glenoid  cavity. 

In  addition  to  these  lesions  of  arteries  and  veins  caused  by  attempts 
at  reduction  of  dislocated  shoulders,  in  both  recent  and  ancient  cases, 
there  are  several  examples  recorded  of  sudden  death  when  no  such 
lesions  were  disclosed  in  the  autopsy.  In  the  case  reported  by  Lis- 
franc  death  was  ascrijDed  to  cerebral  congestion.  MM.  Lenoir  and 
Larrey  refer  to  cases,  also,  of  lesions  of  the  brachial  plexus,  causing 
paralysis,  yet  these  were  recent  cases,  and  the  reduction  was  easily 
accomplished.'^ 

Mr.  Hutchinson,  of  London,  reported  in  1866  that  inflammation,  sup- 
puration, and  death  had  resulted  from  an  attempt  made  to  reduce  an 
old  dislocation  of  the  humerus,  under  his  own  observation.^ 

In  the  following  case  an  attempt  to  reduce  an  ancient  dislocation 
of  the  humerus  occasioned  a  fracture  of  the  surgical  neck. 

Martha  Hogan,  set.  70,  of  Brooklyn,  N".  Y.,  was  admitted  into  the 
Long  Island  College  Hospital  during  the  spring  of  1860.  The  dislo- 
cation had  existed  six  weeks,  and  was  subcoracoid.  On  the  day  of 
admission  an  attempt  was  made  to  reduce  it,  both  by  Dr.  Johnson  and 
myself,  without  an  aneesthetic,  in  which  we  both  failed.  I  then  gave 
her  ether,  and  now  discovered  that  she  had  a  fracture  of  the  second 

'  Pelletan,  Cliir.  Clin.,  t.  ii.  p.  951.  2  Malgaigne,  op.  cit.,  p.  150. 

3  Verduc,  Operat.  de  la  Chir.,  1693,  t.  i.  p.  559. 

*  Malgaigne,  op.  cit.,  p.  152. 

5  Warren,  Amer.  Jouru.  Med.  Sci.,  vol.  xi.  N.  S.  1846. 

'•  Gibson,  Elements  of  Surg.,  vol.  i.  p.  824,  4tli  ed. 

7  Lisfranc,  Lenoir,  Larrej',  Bui.  de  la  Soc.  Chir.,  i.  i. 

8  Lond.  Hosp.  Reports,  vol.  ii.    (See  Cincinnati  Journ.  Med.,  Aug.  18G6,  p.  301.) 


DISLOCATION    WITH    FRACTURE.  565 

and  third  ribs  on  the  same  side.  The  fractures  were  ununited.  While 
manipulating,  pulling  the  arm  gently  and  rotating,  the  surgical  neck 
of  the  humerus  gave  way.  She  did  not  survive  the  injury  many 
days,  and  the  autopsy  confirmed  this  diagnosis.  I  have  seen  the  same 
fracture  caused  by  an  attempt  at  redaction  at  Bellevue. 

Norris  has  reported  three  cases  of  ancient  dislocation  into  the 
axilla,  treated  at  the  Pennsylvania  Hospital;  one,  of  four  weeks' 
standing,  was  reduced  in  thirty  seconds  by  the  aid  of  the  pulleys; 
the  second,  which  had  existed  seven  weeks,  was  reduced  by  the  same 
means  in  about  one  hour;  and  the  third,  dislocated  ten  weeks,  was 
left  unreduced  after  extension  and  counter-extension  had  been  made 
for  an  hour.  In  the  second  case,  however,  suppuration  occurred  in 
or  about  the  joint,  and,  on  the  tenth  day,  the  abscess  was  opened, 
giving  exit  to  a  large  amount  of  pus.  He  left  the  hospital  with  the 
parts  about  the  shoulder  still  much  hardened  and  stiff.' 

Dislocation,  ivith  Fracture  of  the  Humerus  near  its  Upper  End. 

We  have  thus  far  omitted  to  speak  of  the  treatment  of  dislocations 
of  the  humerus  accompanied  with  fracture  near  its  upper  end.  The 
older  writers,  almost  without  an  exception,  agree  in  declaring  the  re- 
duction of  these  dislocations  impossible,  until  the  fracture  had  united. 
And,  so  late  as  the  year  1828,  we  have  the  report  of  a  case  treated  in 
this  manner  by  a  surgeon  in  Massachusetts.  Dr.  Warren,  of  Boston, 
himself  reduced  the  dislocation  at  the  end  of  four  weeks,  when  the 
fracture  was  found  to  have  united.^ 

But  since  the  introduction  of  ansesthetics  immediate  attempts  at 
reduction  have  more  often  proved  successful;  and  in  no  case  can  the 
surgeon  excuse  himself  for  having  omitted  to  make  the  effort. 

Richet  reports  an  example  of  this  kind  in  a  man  sixty-eight  years 
of  age,  in  whom  the  dislocation  was  complicated  with  a  fracture  of 
the  neck  of  the  humerus.  The  attempt  was  not  made  until  the  fourth 
day,  when  it  proved  successful  without  extension.  The  fracture  was 
afterwards  adjusted  and  consolidated  so  that  he  recovered  the  coni- 
plete  use  of  his  arm,^ 

At  a  meeting  of  the  New  York  Academy  of  Medicine,  in  May,, 
1855,  Dr.  Watson  reported  a  case  of  fracture  of  the  humerus  near  its 
head,  complicated  with  a  dislocation  into  the  axilla.  The  patient  was 
a  robust  man,  past  the  middle  age,  and  had  received  the  injury  bj'  a 
blow  on  the  shoulder  from  a  steam-engine.  He  was  very  much  pros- 
trated at  the  time  of  being  admitted  into  the  hospital,  and  the  exami- 
nation was  not  made  until  the  following  morning.  The  arm  was  then 
found  lying  close  to  the  side,  but  in  other  respects  it  presented  the 
usual  signs  of  a  dislocation.  Ether  was  immediately  administered  ; 
and  while  extension  and  counter-extension  were  applied,  and  a  sweep- 
ing motion  given  to  the  arm,  drawing  it  from  the  body,  firm  pressure 

'  Norris,  Amer.  .Tourn.  Med.  Sci.,  xxxi.  p.  34. 

2  Boston  Med.  and  Surg.  Journ.,  No.  i.,  1828;  also,  Amer.  Jouni.  Med.  Sci., 
vol.  ii.  p.  23o. 

•»  Richet,  Amer.  Journ.  Med.  Sci.,  vol.  xii.,  new  sen,  p.  293,  from  I5ulletm  de 
The  rap. 


566  DISLOCATIOXS    OF    THE    SHOULDER. 

with  the  fingers  was  made  in  the  axilla,  forcing  the  head  toward  the 
socket,  and  the  bone  slipped  into  its  position.^ 

In  the  Transactions  of  the  American  Medical  Association,  I  have  re- 
ported a  case  of  supposed  dislocation  accompanied  with  a  fracture, 
which  I  succeeded  in  reducing  on  the  eighth  day.^ 

I  have,  however,  twice  failed  in  attempts  to  reduce  similar  disloca- 
tions. The  first  patient,  John  Riley,  set.  49,  was  admitted  to  Bellevue 
Hospital,  March  29th,  1864,  having  received  the  injury  two  days 
before.  The  dislocation  was  subcoracoid,  and  the  humerus  was 
broken  at  its  surgical  neck.  Having  placed  him  under  the  influence 
of  ether,  assisted  by  Dr.  Stephen  Smith  and  several  other  surgeons  of 
the  hospital,  I  attempted  to  reduce  the  dislocated  bone,  but  after  a 
trial  prolonged  through  one  hour  or  more,  the  effort  was  abandoned. 

The  second  case  was  in  a  man  aged  about  40  years,  who  was  ad- 
mitted to  Bellevue  Hospital  in  July,  1864,  with  a  dislocation  of  the 
head  of  the  humerus  forwards,  and  a  fracture  of  the  surgical  neck,  of 
four  weeks'  standing.  A  surgeon  had  attempted  reduction  immedi- 
ately after  the  receipt  of  the  injury,  but  had  failed.  We  found  the 
fracture  still  ununited,  and  placing  him  under  the  influence  of  ether, 
we  tried  faithfully,  by  pushing  and  pulling  and  by  various  other  ma- 
noeuvres, to  reduce  the  dislocation,  but  without  success. 

The  fractures  united  in  both  cases  promptly,  and  attempts  were 
subsequently  made  to  reduce  the  dislocation,  but  to  no  purpose. 

Other  examples  have  been  recorded  by  surgeons  in  which  the  re- 
duction has  been  accomplished  immediately,  and  without  much  diffi- 
culty, by  simple  pressure  upon  the  head  of  the  bone,  while  the  patient 
was  under  the  influence  of  an  anaesthetic,  and  without  the  aid  of  ex- 
tension ;  indeed,  it  is  quite  doubtful  whether  extension  in  these  cases 
is  of  any  service.  If,  however,  the  surgeon  were  to  fail  by  pressure 
alone,  it  would  be  proper  to  employ  extension  and  manipulation  f  in 
the  event  of  a  failure  by  these  means,  the  case  ought  to  be  treated  as 
a  fracture,  and  the  earliest  period  after  the  union  of  the  fragments 
should  be  seized  upon  to  accomplish  the  reduction  of  the  dislocation. 
The  frequent  success  of  the  older  surgeons  by  this  method  is  sufficient 
to  warrant  the  attempt. 

The  treatment  of  compound  dislocations  of  this  joint  will  be  dis- 
cussed in  a  separate  chapter  devoted  to  the  general  consideration  of 
compound  dislocations  of  all  the  joints  connected  with  the  long  bones. 

§  2.  Dislocation  of  the  Humerus  Forwards.     (Subcoracoid  and 
Subclavicular.) 

Causes. — The  causes  of  this  dislocation  are  the  same  with  those 
■which  produce  dislocation  downwards  into  the  axilla,  except  that  it 
is  more  likely  to  occur  in  a  fall  upon  the  elbow  or  upon  the  hand 
when  the  line  of  the  axis  of  the  arm  and  forearm  is  thrown  behind 

•  Watson,  Amer.  Journ.  Med.  Sci.,  vol.  xvi.,  new  ser.,  p.  383. 

2  Op.  cit.,  vol.  ix.  p.  93. 

3  Hartshorne,  Case  reduced  by  Manipulation,  Amer.  Journ.  Med.  Sci.,  Jan.  1855, 
pp.  273-4,  from  Med.  Examiner. 


DISLOCATIOX    OF    THE    HUMERUS    FORWARDS. 


567 


the  body.  If  it  is  the  result  of  a  direct  blow,  the  impulse  has  usually 
been  received  rather  upon  the  back  than  upon  the  outer  side  of  the 
head  of  the  humerus;  or  the  upper  end  of  the  bone  having  been 
originally  thrown  directly  downwards  upon  the  inferior  edge  of  the 
scapula,  may  have  been  made  to  assume  the  position  forwards,  be- 
neath the  pectoral  muscle,  in  consequence  of  the  peculiar  action  of 
the  muscles,  or  of  the  position  of  the  arm  in  an  attempt  to  rise.  By 
this  latter  mode  of  explanation  the  dislocation  forwards  is  consecu- 
tive only  upon  a  dislocation  downwards. 

In  several  instances  which  have  come  under  my  notice  the  disloca- 
tion has  been  due  to  muscular  action  alone.  In  one  example  the 
dislocation  occurred  frequently  in  consequence  of  epileptic  convul- 
sions. This  was  in  the  person  of  a  lad,  set.  18,  of  a  slender  frame  and 
feeble  muscles.  When  the  dislocation  had  taken  place,  he  was  fre- 
quently able  to  reduce  it  himself;  sometimes  he  was  obliged  to  call 
upon  a  surgeon,  and  at  other  times  he  left  it  out  a  day  or  two,  or 
until  it  became  reduced  spontaneously.  This  spontaneous  reduction 
generally  took  place  at  night,  during  sleep.  At  the  time  he  called, 
upon  me  the  bone  had  been  out  two  days,  and  he  could  not  reduce  it. 
I  administered  chloroform,  and  then  made  repeated  and  prolonged 
efforts  at  reduction,  adopting  all  the  usual  modes  of  manipulation,  but 
without  resorting  to  mechanical  appliances.  The  father  now  refused 
to  allow  me  to  proceed,  and  he  was  taken  home  with  the  bone  unre- 
duced. The  following  day  he  called  at  my  office,  to  say  that  during 
the  night,  while  asleep,  and,  he  thinks,  while  turning  over  in  bed,  the 
bone  suddenly  resumed  its  place. 

Pathology. — Omitting  for  the  present  to  speak  of  partial  luxations, 
the  existence  of  which,  as  a  form  of  traumatic  dislocation,  we  are  pre- 
pared to  question,  we  shall  proceed  at  once  to  describe  the  anatomical 
relations    and    the    various    lesions 
which  generally  accompany  a  com- 
plete luxation  forwards. 

Of  these  we  shall  observe  two 
principal  varieties,  differing  mainly 
in  the  degree  or  extent  of  the  dis- 
placement. 

Thus  we  may  find  the  head  of  the 
humerus  resting  beneath  the  coracoid 
process,  having  the  conjoined  tendon 
of  the  short  head  of  the  biceps  and 
of  the  coraco-brachialis  lying  upon 
its  anterior  surface,  while  its  poste- 
rior and  outer  surface  rests  upon  the 
venter  of  the  scapula  in  front  of  the 
glenoid  fossa;  in. which  position  it 
has  usually  thrust  up,  to  a  greater 
or  less  extent,  the  belly  of  the  sub- 
scapular muscle. 

Sir  Astley  Cooper,  Fergusson,  and  others,  when  mentioning  this 
form  of  dislocation,  call  it  a  "dislocation  into  the  axilla;"  by  Boyer 


Fi:;.  346. 


Subcoracoid  disloc  ition. 


568 


DISLOCATIONS    OF    THE    SHOULDER. 


Fig.  247. 


it  is  called  a  "  primary  luxation  forwards."  Dr.  Wood,  of  New  York, 
has  reported  an  example,  accompanied  with  a  fracture  of  the  neck  of 
the  humerus,  which  he  has  named  "dislocation  under  the  subscapularis 
muscle."  The  drawing  which  accompanied  the  report,  made  from  the 
autopsy,  sufficiently  shows  that  it  was  a  dislocation  of  the  same  char- 
acter as  that  which  we  are  now  describing.^  Dr.  Parker  has  called 
attention  to  a  similar  case,  an  account  of  which  was  first  given  in 
Eeese's  edition  of  Cooper's  Surgical  Dictionary.  The  head  of  the 
humerus  reposed  in  the  "subscapular  fossa."^  By  Malgaigne,  Vidal 
(de  Cassis),  and  others,  this  is  called  a  subcoracoid  dislocation,  a  term 
which,  as  being  more  distinctive  and  appropriate  than  either  of  the 
others,  I  shall  choose  to  adopt. 

In  the  second  variety,  the  head,  having  escaped  from  underneath  the 
coracoid  process,  is  made  to  approach  nearer  to  the  sternum,  so  as  to 
apply  itself  more  or  less  closely  to  the  inferior  edge  of  the  clavicle. 
In  which  case  the  head  and  neck  will  be  placed  behind  the  pectoralis 
minor,  and  also  behind  the  short  head  of  the  biceps  and  coraco-bra- 

chialis;  or  between  these  several  mus- 
cles on  the  one  hand,  and  the  serratus 
magnus,  covering  the  second  and  third 
ribs,  on  the  other  hand. 

Upon  the  appearances  which  accom- 
pany this  more  advanced  form  of  dis- 
location writers  have  generally  based 
their  descriptions,  diagnosis,  treatment, 
&c.,  of  forward  luxations. 

In  either  form  of  the  accident,  the 
deltoid,  with  the  supra-  and  infra-spina- 
tus,  is  greatly  stretched,  and  the  two 
latter  sometimes  torn  ;  the  subscapu- 
laris is  displaced  upwards  and  back- 
wards, while  its  tendon  is  in  some  in- 
stances completely  wrenched  from  the 
head  of  the  humerus.  Mr.  Erichsen 
has  seen  the  lesser  tubercle  itself  com- 
pletely broken  off  in  two  examples  of 
this  accident  which  he  has  been  permitted  to  examine  after  death.^ 
Occasionally  the  axillary  nerves  are  carried  forwards  with  the  head 
of  the  bone;  and  in  this  case  the  pain  produced  by  their  being  thus 
pressed  upon  is  even  greater  than  in  dislocations  into  the  axilla. 

_  In  this  accident,  as  in  dislocation  downwards,  the  long  head  of  the 
biceps  is  sometimes  broken  ;  the  circumflex  nerve  may  be  contused  or 
ruptured,  and  the  capsule  is  generally  torn  very  extensively. 

Symptoms. — If  the  dislocation  is  subclavicular  (Fig.  247),  a  depression 
exists  under  the  outer  end  of  the  acromion  process,  extending  also  un- 
derneath its  posterior  margin ;  the  elbow  hangs  away  from  the  body, 
and  a  little  backwards;  the  axis  of  the  limb  is  much  changed,  being 

'  Wood,  New  York  Journ.  of  Med.,  May,  1850,  p.  282. 

2  Parker,  New  York  Journ.  of  Med.,  March,  1852,  p.  187. 

3  Eiichsen,  Science  and  Art  of  Surgery,  2d  Amer.  ed.,  p.  250. 


Subclavicular  dislocation. 


DISLOCATION    OF    THE    HUMERUS    FORWARDS. 


569 


thrown  inwards  in  tlie  direction  of  the  middle  of  the  clavicle,  the 
whole  body  inclining  moderately  to  the  same  side;  there  is  also  more 
or  less  inability  to  move  the  arm,  especially  in  a  direction  forwards  or 
outwards;  a  fulness  is  seen  underneath  the  clavicle,  and  to  the  sternal 
side  of  the  coracoid  process,  occasioned  by  the  head  of  the  humerus- 
the  head  moving  with- the  shaft.  To  these  we  may  add  the  common 
sign  of  all  dislocations  of  the  humerus,  mentioned  by  Dugas,  viz.,  the 
impossibility  of  placing  the  hand  upon  the  opposite  shoulder  while  at 
the  same  moment  the  elbow  is  made  to  touch  the  front  of  the  chest. 

If  the  dislocation  is  forwards,  but  subcoracoid,  the  head  of  the  bone 
will  be  found  below  this  process  and  deep  in  the  anterior  margin  of 
the  axillary  fossa.  It  cannot,  therefore,  be  so  distinctly  felt ;  but  the 
other  signs  are  the  same  as  in  the  dislocation  forwards  under  the 
clavicle. 

Prognosis. — While  on  the  one  hand  experience  has  shown  that  the 
axillary  nerves  and  artery  are  less  liable  to  suffer  serious  and  permanent 
injury  than  in  dislocation  downwards,  and  that  the  capsule,  with  the 
tendinous  and  muscular  tissues  about  the  joint,  are  no  more  liable  to 
laceration,  on  the  other  hand,  the  difficulty  of  reduction  has  been  often 
increased,  and  consequently  a  large  number  of  examples,  in  propor- 
tion to  the  actual  number  which  occur,  have  been  left  unreduced. 


Fig.  248. 


Subcoracoid  luxation. 


Dr.  Norris  relates  a  case  which  the  surgeon  who  was  first  called 

supposed  to  be  a  mere  contusion,  but  which,  on  being  admitted  to  the 

Pennsylvania  Hospital,  three  months  after  the  accident,  was  found  to 

be  a  dislocation  forwards  under  the  clavicle.     The  arm  was  almost 

87 


570  DISLOCATIONS    OF    THE    SHOULDER. 

useless.  Dr.Norris  made  extension  and  compound  counter-extension 
with  pulleys  nearly  an  hour,  but  to  no  purpose ;  and  finally,  at  the 
request  of  the  patient,  the  attempt  was  given  over/ 

Treatment. — The  same  rules  of  treatment  which  we  have  established 
in  relation  to  dislocations  into  the  axilla  will  be  found  to  be  applicable 
to  this  dislocation,  with  the  exception  that  the" extension  will  have  to 
be  made  generally  at  first  somewhat  in  a  line  backwards  from  the 
body,  and  that  our  efforts  will  frequently  have  to  be  continued  with 
more  perseverance,  although  with  less  fear  of  injury,  in  consequence 
of  supposed  adhesions  between  the  artery  and  the  adjacent  tissues. 
The  extension  also  must  always  be  made  downwards  and  outwards, 
if  the  dislocation  is  subclavicular,  until  the  head  of  the  bone  has  es- 
caped from  beneath  the  coracoid  process ;  we  may  then  pull  directly 
outwards  or  even  upwards,  while  at  the  same  moment  pressure  is 
made  with  the  hand  upon  the  head  of  the  bone  in  the  direction  of  the 
socket,  and  the  arm  is  rotated  inwards. 

If  the  dislocation  is  subcoracoid,  our  modes  of  procedure  need 
scarcely  vary  in  any  respect  from  those  which  we  have  recommended 
for  dislocations  into  the  axilla. 

The  plan  adopted  in  the  following  case  has  been  found  sufficient  in 
several  examples  of  subcoracoid  dislocation, 

Mr.  McA.,  of  Buffalo,  fet.  73,  moderately  muscular,  fell  through  a 
trap-door,  striking  upon  his  right  elbow,  and  dislocating  the  humerus 
forwards.  Within  two  hours  after  the  accident,  I  found  the  head  of 
the  bone  resting  under  the  coracoid  process,  where  it  could  be  dis- 
tinctly felt  and  seen.  There  was  a  marked  depression  under  the 
acromion  process,  and  the  arm  was  carried  out  from  the  body  and 
slightly  back.  He  had  not  suftered  much  pain.  The  patient  was 
seated  in  a  chair,  and  while  Dr.  Lemon,  who  was  at  that  time  my 
pupil,  supported  the  acromion  process,  I  pushed  the  head  of  the  hu- 
merus outwards  toward  the  socket  with  my  left  hand,  while  with  my 
right  I  pulled  gently  upon  the  arm  in  the  direction  of  the  axis  of  the 
body.  After  about  twenty  seconds  it  slid  suddenly  into  its  place* 
with  an  audible  snap. 

Simple  manipulation  alone  will  also  be  found  sufficient  in  many 
cases  of  subclavicular  dislocation. 

A  German,  Simeon  Grenuas,  £et.  21,  fell  upon  an  icy  side-walk,  and 
dislocated  his  right  humerus  under  the  clavicle.  We  found  him  about 
■an  hour  after  the  accident  sitting  with  his  head  inclined  to  his  right 
side,  and  supporting  his  elbow  with  his  left  hand.  A  marked  depres- 
sion existed  under  the  outer  end  of  the  acromion  process,  and  instead 
of  the  usual  fulness  there  was  a  flatness  under  the  process  behind. 
The  elbow  was  carried  out  from  the  body,  and  very  slightly  backwards. 
While  Dr.  Boardman  supported  the  acromion  process  I  lifted  the 
elbow  from  the  side,  carrying  it  first  upwards  and  backwards,  and 
then  forwards,  making  thus  a  short  detour  with  the  arm,  and  when 
the  manoeuvre  was  nearly  completed  the  bone  slid  into  its  socket 
with  a  slight  snap.     No  extension  was  used,  and  no  more  force  was 

'  Norris,  Amer.  Journ.  Med.  Sci.,  vol.  xxv.  p.  279. 


DISLOCATION    OF    THE    HUMEEUS    FORWARDS.  571 

employed  than  was  sufficient  to  lift  and  rotate  the  arm.  He  was  not 
at  the  time  of  the  reduction  faint,  nor  were  his  muscles  relaxed  from 
any  other  cause. 

More  than  once  I  have  accomplished  the  reduction  by  extension 
made  directly  upwards,  as  in  the  following  example. 

A  gentleman,  forty-five  years  of  age,  had  his  left  shoulder  dislocated 
forwards  under  the  clavicle  in  a  railroad  collision,  on  the  8th  of  Octo- 
ber, 1858.  A  young  surgeon  had  been  making  extension  in  various 
ways  for  half  an  hour,  when,  by  placing  my  foot  upon  the  top  of  the 
scapula  and  drawing  the  arm  directly  upwards,  I  accomplished  the 
reduction  immediately  and  without  much  effort.  Six  months  after 
the  accident,  I  found  the  deltoid  muscle  considerably  wasted,  and  he 
was  still  unable  to  raise  his  arm  to  a  right  angle  with  the  body. 

I  have  in  this  way  also  reduced  a  dislocation  which  had  existed 
seventeen  days,  the  nature  of  the  accident  having  been  misunderstood 
by  the  attending  surgeon.  The  man  was  twenty-three  years  old,  and 
quite  muscular.  The  dislocation  had  been  produced  by  a  severe  blow 
received  directly  upon  the  shoulder,  and  the  arm  was  still  considerably 
swollen  and  very  tender.  The  reduction  was  accomplished  in  a  few 
seconds  while  the  patient  was  under  the  influence  of  chloroform,  but 
by  my  hands  alone,  aided  only  by  the  pressure  of  the  foot  upon  the 
top  of  the  scapula. 

In  December,  1857,  Dr.  White,  of  Buffalo,  and  myself,  reduced  a 
subclavicular  dislocation  of  the  right  shoulder,  which  had  existed  sixty 
days,  in  a  man  sixty-eight  years  of  age.  The  surgeon  who  first  saw 
the  man  thought  it  was  only  a  sprain  or  a  severe  bruise.  When  he 
came  to  Buffalo,  the  whole  limb  was  enormously  swollen,  and  neither 
Dr.  White  nor  myself  had  much  expectation  of  accomplishing  a  re- 
duction without  a  resort  to  pulleys  and  aneesthetics.  He  was,  however, 
placed  upon  the  floor,  and  after  extension  made  for  about  half  an 
hour,  during  which  time  we  had  pulled  the  arm  in  various  directions, 
upwards,  outwards,  and  downwards,  I  at  last  succeeded  while  my  heel 
was  placed  in  the  axilla,  and  while  the  limb  was  undergoing  a  slight 
rotation.     No  anaesthetic  was  employed. 

Dr.  M.  C.  Cuykendall,  of  Bucyrus,  Ohio,  informs  me  that  he  has 
recently  reduced  a  subclavicular  dislocation  on  the  sixty-fourth  day, 
in  a  man  62  years  old,  by  the  following  method :  "As  a  last  resort  I 
secured  the  pulleys  to  the  arm  above  the  elbow,  making  the  counter- 
extension  with  Skey's  knob  in  the  axilla,  flexed  the  arm  and  made 
extension  downwards  and  forwards ;  and  when  well  extended  I  moved 
his  body  under  the  pulley  ropes,  so  as  to  bring  the  arm  ibrcibly 
across  the  breast,  and  then,  keeping  up  the  extension,  I  had  Dr. 
Eichey  place  his  knee  upon  the  top  of  the  scapula,  and  lock  his  fingers 
around  the  elbow,  while  I  placed  my  knee  against  the  elbow  and 
locked  my  fingers  around  the  top  of  the  scapula,  and  directing  the 
extension  removed,  we  forced  the  bone  upwards  and  outwards  to  its 
socket;"  adhesions  were  felt  to  give  way,  and  the  restoration  of  the 
bone  was  found  to  be  complete. 

It  will  be  understood  that  this  method  did  not  succeed  until  after 
repeated  and  long-continued  efforts  had  been  made  by  other  methods. 


572  DISLOCATIONS    OF    THE    SHOULDER. 

such  as  pulling  down,  pulling  out,  and  pulling  directly  up.  Dr.  Cuy- 
kendall  informs  me  that  this  is  the  second  time  he  has  succeeded  in 
"  completing"  the  reduction  of  old  dislocations  of  the  shoulder  by  this 
manoeuvre. 

These  several  cases  are  mentioned  that  the  surgeon  may  understand 
how  impossible  it  is  always  to  establish  absolute  and  invariable  rules 
of  procedure  which  shall  be  applicable  to  every  accident  of  this  cha- 
racter. The  method  which  will  succeed  readily  in  one  case  may  fail 
completely  in  another,  although  belonging  to  the  same  class,  and  not 
apparently  differing  in  its  anatomical  relations.  Before  relinquishing 
the  attempt,  we  ought  to  have  put  into  requisition  all  the  expedients 
which  the  experience  of  other  surgeons  has  shown  to  be  worthy  of  a 
trial. 

During  the  year  of  1865,  two  ancient  subcoracoid  dislocations  came 
under  my  observation  at  Bellevue  Hospital.  One  of  these  cases,  in  the 
person  of  James  Thompson,  £et.  49,  had  existed  two  years  or  more. 
He  was  employed  about  the  hospital  as  a  carpenter,  and  has  a  tolera- 
bly useful  arm.  The  second,  in  the  person  of  Rosanna  Casey,  aet.  32, 
had  existed  six  weeks  when  she  was  admitted.  Various  attempts  had 
been  made  to  reduce  the  dislocation  before  admission.  During  the 
week  following  her  admission  an  attempt  was  made  at  reduction  by 
Dr.  Verona,  an  intelligent  house  surgeon,  subsequently  by  Dr.  James 
R.Wood,  and  at  the  end  of  three  months  the  attempt  was  made  by 
myself,  before  the  class  of  medical  students,  the  patient  being  each 
time  under  the  influence  of  an  anaesthetic.  She  was  finally  discharged 
with  the  bone  still  unreduced. 

Mary  Coffee,  vet.  46,  was  admitted  also  to  the  Charity  Hospital,  in 
Feb.  1864,  with  the  same  dislocation,  which  had  existed  six  months, 
having  been  mistaken  at  first  for  a  fracture.  1  found  her  arm  free 
from  swelling  or  paralysis,  and  moving  quite  freely  in  its  new  socket, 
and  declined  to  make  any  attempt  at  reduction. 

§  3.  Dislocation  of  the  Humerus  Backwards.     (Subspinous.) 

This  form  of  dislocation  has  been  seldom  met  with.  Only  two 
cases,  according  to  Sir  Astley  Cooper,  occurred  in  Guy's  Hospital  in 
thirty-eight  years;  but  in  the  last  edition  of  Sir  Astley  Cooper's 
treatise  on  Fractures  and  Dislocations,  edited  by  Bransby  Cooper,  nine 
cases  are  mentioned.'  Sedillot,^  Malgaigne,  Desclaux,^  Van  Buren,^ 
W.  Parker,^  Lepelletier,^  Trowbridge,^  Physick,  Snyder/  and  myself, 
have  each  seen  one  example.  Examples  have  also  been  seen  by  Du- 
puytren,  Arnolt,  Best,  Levacher,  Berard,  Fizeau,  Velpeau,  Fergusson, 
Kirkbride,^  and  by  Rogers.'** 
« 
'  A.  Cooper,  op.  cit.,  p.  352. 

2  Sedillot,  Amer.  Journ.  of  Med.  Sci.,  vol.  xiii.  p.  551,  Feb.  1834. 

3  Desclaux,  New  York  Jouru.  of  Med.,  Nov.  1851,  p.  109,  from  Revue  Medicale. 
■•  VanBuren,  ibid.,  Nov.  1851,  p.  110. 

5  Parker,  ibid.,  March,  1852,  p.  186. 

6  Lepelletier,  Amer.  Journ.  Med.  Sci.,  vol.  xvi.  p.  526,  from  Arch.  Gen.,  Nov.  1834. 
'  Trowbridge,  Bost.  Med  and  Surg.  Journ..  vol.  xxvii.  p.  99. 

«  Gibson's  Surgery.  s  Xew  York  Jouru.  Med.,  March,  1852. 

'"  Amer.  Med.  Times,  November,  9. 


DISLOCATION    OP    THE    HUMERUS    BACKWARDS.  573 

Causes. — One  of  the  patients  mentioned  in  Mr.  Cooper's  book  had 
his  shoulder  dislocated  backwards  in  an  epileptic  convulsion ;  one  had 
fallen  upon  his  shoulder  ;  another  met  with  the  accident  while  push- 
ing a  person  violently  with  the  arm  elevated ;  and  a  fourth,  seen  by 
Coley,  was  "pulled  down  by  a  calf  which  he  was  driving,  a  cord  hav- 
ing been  tied  to  one  of  the  calf's  legs,  and  being  held  fast  by  the 
man's  hand."  My  own  patient,  Frederick  Kretner,  had  his  arm  caught 
in  machinery  on  the  14th  of  January,  1860.  The  dislocation  was  dis- 
covered when  I  was  preparing  to  amputate  the  arm  soon  after  the 
accident  occurred.  Of  the  manner  in  which  the  other  cases  were  pro- 
duced no  precise  account  is  given.  Desclaux's  patient  fell  from  a 
height  with  his  arm  in  front  of  him.  In  the  case  seen  by  Dr.  Parker, 
of  New  York,  a  woman,  ^t.  60,  had  fallen  forwards  and  struck  upon 
the  outside  of  her  elbow,  arm,  and  shoulder.  No  attempt  was  made 
to  reduce  it  until  the  fourteenth  day,  she  not  having  for  some  time 
called  the  attention  of  any  surgeon  to  its  condition.  Trowbridge's 
patient  was  thrown  from  a  horse,  striking  on  the  palm  of  his  hand. 

Pathology. — Mr.  Cooper  has  given  us  a  careful  account  of  the  dis- 
section in  the  case  of  Mr.  Complin,  already  alluded  to,  whose  arm  had 
been  dislocated  by  muscular  spasm.  This  gentleman  was  fifty-two 
years  of  age,  and  had  been  subject  to  epileptic  fits,  in  one  of  which  the 
shoulder  was  dislocated.  Many  attempts  were  made  to  reduce  it,  but 
although  it  seemed  to  be  easily  drawn  into  its  socket  by  extension 
merely,  yet,  as  soon  as  the  force  ceased,  the  head  of  the  bone  slipped 
again  upon  the  dorsum  scapulae,  and  in  this  situation  it  was  finally 
permitted  to  remain  until  his  death,  which  did  not  take  place  until 
five  years  after.  In  the  meantime  he  was  able  to  move  the  limb  but 
very  slightly,  so  that  his  arm  was  almost  useless. 

Mr.  Cooper,  to  whom  the  arm  was  sent  after  death,  found  the  head 
of  the  bone  resting  under  the  spine  of  the  scapula,  and  against  the 
posterior  edge  of  the  glenoid  fossa,  where  it  had  formed  a  slight  de- 
pression, and  the  head  itself  had  become  somewhat  changed  in  form 
by  absorption.  The  tendon  of  the  subscapularis  muscle  and  the 
internal  portion  of  the  capsular  ligament  were  torn  at  the  point  where 
the  muscle  was  inserted,  but  the  greater  portion  of  the  capsule  re- 
mained, having  been  pressed  back  by  the  head  of  the  bone.  The 
supra-spinatus  was  stretched,  while  the  infra-spinatus  and  teres  minor 
were  relaxed.  The  long  head  of  the  biceps  was  elongated,  but  not 
ruptured.  The  glenoid  fossa  was  rough  and  irregular  upon  its  sur- 
face, the  cartilage  being  absorbed. 

The  fact  that  the  bone  would  not  remain  in  place  when  reduced, 
was  explained  by  the  rupture  of  the  subscapularis,  and  the  consequent 
loss  of  antagonism  to  the  action  of  the  infra-spinatus  and  teres  minor.^ 

The  accompanying  drawing  is  a  copy  of  that  furnished  by  Mr. 
Cooper,  to  illustrate  the  position  occupied  by  the  bone. 

I  ought  to  mention  that  this  case  has  been  regarded  by  Vidal  (de 
Cassis),  Malgaigne,  and  others,  as  only  subacromial,  and  as  a  variety 
of  the  dislocation  backwards,  differing  from  that  in  which  the  head 

'  Sir  Astley  Cooper,  op.  cit.,  p.  354. 


574 


DISLOCATIONS    OF   THE    SHOULDER. 


Subspinous  dislocation. 


Fig.  249.  of  the  bone  occupies  a  position  under- 

neath the  spine.  But  as  I  can  see  no 
difference  except  in  the  degree  or  ex- 
tent of  the  displacement,  I  prefer  not 
to  regard  the  distinction  made  by  these 
surgeons. 

Symptoms. — The  signs  of  this  accident 
are,  a  projection  under  the  spine  of  the 
scapula,  produced  by  the  head  of  the 
bone,  the  head  being  obedient  to  the 
motions  of  the  arm ;  a  corresponding 
depression  in  front  and  under  the  outer 
extremity  of  the  acromion  process ;  a 
wide  space  between  the  head  of  the  bone 
and  the  coracoid  process,  into  which  the 
fingers  may  be  pushed  deeply;  the  axis 
of  the  shaft  of  the  humerus  directed  up- 
wards and  outwards  toward  a  point  posterior  to  the  glenoid  fossa; 
the  forearm  carried  forwards  across  the  chest;  the  humerus  rotated 
inwards,  unless  the  subscapularis  muscle  is  torn;  immobility,  but  the 
motions  of  the  arm  are  not  generally  so  much  impaired  as  in  either 
of  the  other  dislocations;  and  finally,  as  in  all  other  dislocations  of 
the  humerus,  the  hand  cannot  be  laid  upon  the  opposite  shoulder 
while  the  elbow  touches  the  front  or  side  of  the  chest.  In  Parker's 
case  the  elbow  was  thrown  outwards,  although  the  arm  was  carried 
very  much  across  the  chest.  Desclaux's  patient  held  bis  hand  upon 
his  head,  with  his  arm  horizontally  across  his  body. 

Usually  the  diagnosis  will  be  easily  made ;  in  my  own  case  the 
position  of  the  head  of  the  bone  was  easily  recognized,  but  Sir  Astley 
relates  one  case  in  which,  on  the  morning  following  the  accident,  a 
surgeon  was  unable  to  discover  the  dislocation,  and  on  the  seventeenth 
day  Bransby  Cooper  failed  to  make  the  diagnosis;  nor,  indeed,  on  the 
twenty-third  day  did  Sir  Astley  himself  determine  that  it  was  a 
dislocation,  until  he  had  unexpectedly  reduced  it  while  manipulating 
upon  the  arm.  In  a  second  example,  Sir  Astley  at  first  believed  it 
to  be  a  fracture,  but  a  more  careful  examination  showed  it  to  be  a  dis- 
location backwards.  In  this  instance  the  limb  could  not  be  rotated 
outwards,  as  the  subscapularis  was  not  torn,  and  continued  to  offer 
resistance  when  the  arm  was  moved  in  this  direction ;  he  was  also 
suffering  much  more  pain  than  did  the  other  patients,  owing,  as  Sir 
Astley  thinks,  to  pressure  upon  the  articular  nerves.  In  the  case  of 
Mr.  Collinson,  also  mentioned  by  Mr.  Cooper,  a  surgeon,  who  saw  the 
patient  immediately  after  the  accident,  failed  to  discover  the  true 
nature  of  the  injury;  and  Trowbridge's  patient  had  suffered  a  dislo- 
cation several  weeks  before  the  nature  of  the  accident  was  fully 
determined. 

Prognosis. — The  reduction  has  always  been  sooner  or  later  accom- 
plished, except  in  one  instance ;  in  this  case  we  have  seen  that  the  arm 
never  recovered  any  considerable  degree  of  usefulness.  Mr.  Collinson's 
arm,  reduced  on  the  second  day,  was  restored  to  all  of  its  functions 


DISLOCATION    OF    THE    HUMERUS    BACKWARDS.         575 

within  one  montli.  Dr.  Parker's  patient  had  nearly  recovered  the 
complete  use  of  her  arm  at  the  end  of  four  weeks,  although  it  was  not 
reduced  until  it  had  been  out  fourteen  days.  Sedillot  succeeded  in 
reducing  the  dislocation  in  the  case  of  his  patient,  at  the  end  of  one 
year  and  fifteen  days.  Lepelletier,  after  forty-five  days.  Trowbridge, 
after  forty  days ;  and  in  this  latter  case  we  are  informed  that  the  arm 
was  restored  to  usefulness. 

Treatment. — In  the  first  case  mentioned  by  Sir  Astley  Cooper,  "the 
bandages  were  applied  in  the  same  manner  as  if  the  head  of  the  hume- 
rus had  been  in  the  axilla,  and  the  extension  was  made  in  the  same 
direction  as  in  that  accident"  (downwards  and  a  little  outwards).  In 
less  than  five  minutes  the  bone  slipped  into  its  socket  with  a  loud  snap. 
The  second  case  was  treated  successfully  in  the  same  way.  Mr.  Dunn 
also  having  failed  to  reduce  by  pulling  upwards,  finally  succeeded  by 
pulling  at  the  wrist  downwards  and  forwards,  while  an  assistant  pushed 
the  head  of  the  bone  toward  the  socket;  the  heel  was  not  placed  in 
the  axilla,  which  Mr.  Bransby  Cooper  thinks  would  have  only  retarded 
the  reduction.  Mr.  Key  also  failed  to  accomplish  reduction  while  car- 
rying the  arm  upwards  and  backwards,  but  when  the  patient  had  be- 
come faint,  by  placing  the  heel  in  the  axilla  and  pulling  downwards  a 
minute  or  two,  the  bone  was  reduced.  Vidal(de  Cassis)  recommends 
the  same  plan,  namely,  that  we  shall  pull  in  the  direction  in  which  we 
find  the  limb;  Trowbridge  employed  the  pulleys  successfully,  the  ex- 
tension being  made  downwards  and  forwards;  while  Dr.  Parker  suc- 
ceeded equally  well  with  his  patient,  by  "  pulling  the  arm  outwards, 
downwards,  and  slightly  forwards."  Counter-extension  was  at  the 
same  time  made  by  a  sheet  in  the  axilla,  and  the  head  of  the  humerus 
was  pushed  toward  the  socket  by  the  hand.  In  Mr.  Coliinson's  case, 
the  scapula  was  supported  by  a  towel,  while  "gradual  extension  of  the 
limb  was  made  directly  outwards,  and  then  the  arm  being  moved 
slowly  forwards,  the  head  of  the  bone  was  distinctly  heard  to  snap  into 
its  socket."  The  time  occupied  was  not  more  than  two  or  three 
minutes.  Rogers  succeeded  by  N.  R.  Smith's  method.  Sir  Astley, 
however,  seems  to  give  the  preference  to  the  method  which  succeeded 
so  happily  in  the  case  of  Mr.  G.,  while  he  was  still  manipulating  with 
a  view  to  determine  the  character  of  the  accident.  "  I  readily  reduced 
the  bone,"  he  remarks,  "  by  raising  the  hand  and  arm,  and  by  turning 
the  hand  backwards  behind  the  head."  In  one  other  instance,  having 
failed  to  reduce  it  by  slight  extension  outwards,  he  raised  the  arm 
perpendicularly,  at  the  same  time  forced  it  backwards  behind  the 
patient's  head,  and  the  reduction  was  promptly  effected.  In  the  case 
of  Kretner,  I  first  attempted  reduction  by  pressure  directly  upon  the 
head  of  the  humerus;  but  failing,  I  proceeded  to  pull  the  arm  with 
moderate  force  outwards  and  downwards,  which  procedure  was 
attended  with  immediate  success.  The  patient  was  under  the  influence 
of  chloroform. 

After  the  reduction,  a  compress  should  be  placed  against  the  head 
of  the  bone,  and  underneath  the  spine  of  the  scapula,  and  this  should 
be  secured  in  its  place  by  several  turns  of  a  roller.     The  forearm 


576  DISLOCATIONS    OF    THE    SHOULDER. 

ought  also  to  be  placed  in  a  sling,  with  the  elbow  thrown  a  little  back 
of  the  centre  of  the  body,  so  as  to  direct  the  head  of  the  humerus 
forwards. 

§  4.  Partial  Dislocations  of  the  Humerus. 

Sir  Astlej  Cooper  has  related  in  his  treatise  two  cases  of  supposed 
incomplete  luxation  of  the  head  of  the  humerus  forwards ;  and  in  con- 
firmation of  his  views  he  has  added  an  account  of  the  appearances 
presented  on  dissection  in  the  body  of  a  subject  brought  into  the 
rooms  of  St.  Thomas's  Hospital.  Bransby  Cooper,  in  his  edition  of 
the  same  work,  furnishes  the  report  of  a  similar  case  which  came 
under  the  observation  of  Mr.  Douglass,  of  Glasgow.  Hargrave  and 
Dupuytren  have  each  reported  one  example  of  this  species  of  dislo- 
cation, in  which  its  existence  was  said  to  be  confirmed  by  dissection. 

Petit,  Duverney,  Chopart,  Sedillot,  Miller,  Gibson,  Malgaigne,  and 
many  others,  have  admitted  its  possibility  ;  Malgaigne,  however,  only 
admits  its  existence  when  the  capsule  remains  entire. 

Without  intending  to  discuss  very  much  at  length  the  value  of 
these  opinions,  I  shall  content  myself  with  declaring  that  the  exist- 
ence of  this  or  of  any  other  form  of  partial  luxation  of  the  shoulder- 
joint,  as  a  traumatic  accident,  has  not  up  to  this  moment  been  fairly 
established  ;  and  that  the  anatomical  structure  of  the  joint  renders  its 
occurrence  exceedingly  improbable,  if  not  absolutely  impossible. 

The  only  example  mentioned  by  Sir  Astley  Cooper,  in  which  a 
dissection  was  made,  showed  that  the  long  head  of  the  biceps  had 
been  ruptured,  and  that  the  capsule  was  torn,  while  the  head  of  the 
humerus  was  resting  under  the  coracoid  process.  We  shall  have  no 
difficulty,  therefore,  in  assigning  it  to  its  proper  place  as  a  complete 
subcoracoid  dislocation.  In  Mr.  Hargrave's  case,  also,  the  tendon  of 
the  biceps  was  torn  ;  while  Dupuytren  omits  to  mention  what  was  the 
actual  fact  in  relation  to  this  tendon  in  the  case  seen  by  him,  but  it  is 
distinctly  stated  that  the  head  of  the  bone  rested  upon  the  ribs.  Mr. 
Hargrave  seems,  therefore,  to  have  described  a  case  of  rupture  of  the 
long  head  of  the  biceps,  and  it  is  probable  that  Dupuytren,  who  knew 
nothing  of  the  previous  history  of  the  subject,  has  given  us  a  faithful 
account  of  a  pathological  dislocation,  a  result  of  disease,  and  not  of  a 
direct  injury. 

If  the  head  of  the  humerus  is  driven  from  its  socket  by  violence, 
and  remains  thus  displaced,  it  is,  we  assume,  a  complete  luxation; 
since  it  is  only  by  having  placed  the  semi-diameter  of  the  head  of  the 
bone  outside  of  the  margin  of  the  glenoid  fossa  that  it  can  be  made 
for  one  moment  to  retain  its  abnormal  position.  To  accomplish  this 
amount  of  displacement  upwards,  or  upwards  and  forwards,  or  directly 
forwards,  the  acromion  or  the  coracoid  process  must  be  broken  ; 
while  its  occurrence  in  any  other  direction  must  involve  at  least  a 
most  extraordinary  extension,  if  not  an  actual  laceration,  of  the  cap- 
sule. If  we  admit,  with  Malgaigne,  that  occasionally  the  capsule  has 
been  found  capable  of  such  extraordinary  extension  without  actual 
rupture,  we  still  are  unwilling  to  regard  this  as  a  fair  example  of  a 


PAKTIAL    DISLOCATIONS    OF    THE    HUMERUS. 


77 


partial  dislocation,  since  the  head  of  the  bone  no  longer  moves  in  its 
socket,  being  at  no  point  in  actual  contact  with  the  articular  surface 
of  the  glenoid  fossa.  It  is  essentially  a  complete  dislocation,  accord- 
ing to  all  the  admitted  definitions  of  this  term. 

It  is  quite  probable  that  a  majority  of  these  accidents  were  examples 
of  rupture  or  of  displacement  of  the  tendon  of  the  long  head  of  the 
biceps,  the  effect  of  which,  as  Mr,  John  G.  Smith'  and  Mr.  Soden^  have 
shown  by  a  number  of  dissections,  is  to  allow  the  head  of  the  humerus 
to  be  drawn  upwards  and  forwards  in  its  socket,  until  it  is  arrested  by 
the  two  processes,  and  by  the  coraco-acromial  ligament.  Says  Mr. 
Soden,  "To  enable  the  bone  to  maintain  its  equilibrium,  it  is  necessary 
that  the  capsular  muscles  should  exactly  counterbalance  each  other; 
and  as  there  is  no  muscle  from  the  ribs  to  the  humerus  to  antagonize 
the  upper  capsular  muscles"  (that  is,  to  draw  the  head  of  the  humerus 
downwards),  "  it  is  suggested  that  this  office  is  performed  by  the  sin- 
gular course  of  the  long  tendon  of  the  biceps,  which,  by  passing  over 
the  head  of  the  bone,  when  the  muscle  is  put  in  action,  tends  to  throw 
the  head  downwards  and  backwards  ;  it  follows,  therefore,  that,  the 
tendon  being  removed,  the  head  of  the  bone  would  rise  upwards  and 
forwards." 

The  drawing  (Fig,  250)  represents  the  case  of  displacement  of  the 
tendon  of  the  biceps  seen  by  Mr.  Soden,  and  of  which  he  had  been 
permitted  to  make  a  dissection.^ 

1  have  myself  frequently  observed,  and  I  have  before,  when  speaking 
of  the  prognosis  or  results  of  dislocations,  called  attention  to  the  fact, 
that  the  head  of  the  humerus  some- 
times remains  for  a  long  time  after 
the  reduction  lias  been  effected  slight- 
ly advanced  in  its  socket,  so  as  to  lead 
to  a  suspicion  that  it  is  not  properly 
reduced.  Quite  recently  I  have  been 
consulted  in  the  case  of  a  lad  about 
fourteen  years  of  age,  who  had  been 
subjected  to  the  pulleys  during  four 
consecutive  hours  to  accomplish  a 
more  complete  reduction. 

The  same  thing,  also,  has  been 
noticed  by  me  occasionally  where 
the  shoulder  had  been  subjected  to 
a  violent  wrench,  but  no  actual  dis- 
location had  ever  occurred.  In  either 
case  the  explanation  is  perhaps  the 
same,  the  long  head  of  the  biceps  has 
been  broken  or  displaced  ;  or,  when  it  follows  a  dislocation,  some  of  the 
muscles  inserted  into  the  greater  tuberosity  have  been  torn  from  their 
attachments.     I  mean  to  say  that  in  these  circumstances  we  may  find 

'   Amor.  .Tourn.  Med.  Sci.,  vol.  xvi.  p.  210,  Miiy,  18:55,  iVom  Lond.  Med.  Gaz. 

2  Ibid.,  vol,  xxix.  p.  480,  from  Lond.  Med.  Uuz.,  July,  1841. 

'  Pirrie's  System  of  Surg.,  Amer.  ed.,  p.  355;  also,"  Sir  Astley  Cooper,  edited 
by  Bransby  Cooper,  Amer.  cd.,  p.  3G3. 


Fior.  250. 


UiHpliicoinont  of  (lio  loDg  lieail  of  tlio  bicops. 


578  DISLOCATIONS    OF    THE    SHOULDER. 

a  sufficient  and  perhaps  the  most  frequent  explanation;  yet  it  is  quite 
probable  that,  in  a  considerable  number  of  cases,  the  laceration  of  the 
capsule,  and  the  action  of  the  muscles,  are  alone  concerned  in  the 
production  of  this  phenomenon,  I  have  seen  one  example  in  the 
person  of  Mr.  Craig,  of  Brooklyn,  in  which  the  tendon  of  the  biceps 
suddenly  resumed  its  position  after  the  lapse  of  several  days,  and  the 
prominence  of  the  head  of  the  humerus  at  once  disappeared. 

Alfred  Mercer,  of  Syracuse,  N.  Y.,  in  a  very  interesting  paper  on 
this  same  subject,  relates  several  examples  of  forward  displacement 
after  injuries  to  the  shoulder-joint,  one  of  which,  as  being  exceedingly 
pertinent,  I  shall  take  the  liberty  of  quoting. 

"Mrs.  B,  a  well-developed  woman,  of  full  habit,  aged  fifty-six,  seven 
years  since  was  thrown  from  a  carriage,  dislocating  her  right  shoulder, 
which  was  reduced  a  short  time  after  the  accident,  but  the  shoulder 
was  painful,  and  tender  to  the  touch,  and  almost  useless  for  months 
after.  She  could  carry  the  arm  forwards  and  backwards,  but  could 
not  raise  it  from  the  side,  or  carry  the  hand  behind  her,  or  raise  it  to 
her  head,  for  fourteen  months.  She  has  gradually  gained  better  use 
of  her  arm,  but  now,  July,  1858,  she  cannot  raise  her  elljow  from  the 
side  more  than  half-way  to  a  horizontal  position  without  assistance; 
but  with  assistance,  the  arm  may  be  carried  into  any  position  without 
pain  or  resistance.  Measurement  shows  no  appreciable  diftbrence  in 
the  size  or  length  of  the  arm,  or  size  of  the  shoulder  ;  but  the  point  of 
the  shoulder  is  still  tender  to  the  touch,  is  prominent  in  front,  and 
correspondingly  flattened  behind.  The  head  of  the  humerus  appears 
to  rest  against  the  outside  of  the  coracoid  process,  but  the  fulness  of 
habit  obscures  the  diagnosis,  compared  with  the  other  cases.  Several 
doctors,  at  different  times,  have  examined  the  shoulder ;  some  have 
said  it  was  not  properly  reduced,  and  advised  a  suit  for  malpractice. 

"  I  examined  the  shoulder  again  in  November  last ;  it  presented  the 
same  general  appearance,  although  the  patient  was  much  thinner  in 
flesh  from  recent  sickness.  Some  six  weeks  previous  to  this  exami- 
nation, in  a  sudden  and  thoughtless  effijrt  to  raise  the  arm  above  the 
head,  the  muscles  unexpectedly  obeyed  the  will;  since  which  time 
she  has  had  perfect  use  of  it,  though  the  deformity  still  remains.  She 
thinks  she  felt  or  heard  a  snap  when  the  arm  went  up,  but  it  was 
followed  by  no  pain,  soreness,  or  swelling.'" 

There  can  be  no  doubt,  we  think,  that  in  this  case,  at  least,  the 
deformity  and  maiming  were  due  in  a  great  measure  to  a  displace- 
ment of  the  long  head  of  the  biceps.- 

'  Mercer,  Buffalo  Med.  Journ.,  vol.  xiv.  p.  041,  April,  1859. 
2  BroomfieUrs  Cliirurg.  Observ.,  vol.  ii.  p.  76. 


DISLOC'ATIOXS    OF    HEAD    OF    RADIUS    FORWARDS.      579 


CHAPTER    VII. 

DISLOCATIONS  OF  THE  HEAD  OF  THE  RADIUS. 

I  HAVE  met  with  twenty-three  examples  of  traumatic  dislocation  of 
the  head  of  the  radius ;  of  which  nineteen  were  dislocated  forwards, 
or  forwards  and  outwards,  and  only  four  backwards :  or,  rejecting 
those  cases  which  were  complicated  with  fracture,  I  have  recorded 
nine  cases  of  simple  forward  luxation,  and  two  of  simple  backward 
luxation.  My  experience,  therefore,  does  not  correspond  with  the 
experience  of  Boyer,  Velpeau,  Vidal  (de  Cassis),  Chelius,  B.  Cooper, 
Guthrie,  Gibson,  and  some  others,  who  declare  that  the  dislocation 
backwards  is  the  more  frequent  of  the  two.  Indeed,  I  ought  to  say 
of  both  of  tne  examples  of  backward  luxation  of  the  radius  which 
have  come  under  my  notice,  and  which  I  have  marked  as  simple,  that 
they  were  ancient  luxations,  and  I  am  not  entirely  certain,  therefore, 
that  they  had  not  been  originally  complicated  with  a  fracture,  although 
at  the  time  of  my  examination  they  presented  no  such  evidence.  I 
have  seen  one  congenital  dislocation  of  the  head  of  the  radius  outward 
and  forward,  which  I  will  describe  more  particularly  in  the  chapter 
on  congenital  dislocations. 

§  1.  Dislocations  op  the  Head  of  the  Radius  Forwards. 

Causes. — A  fall  upon  the  elbow,  the  blow  being  received  directly 
upon  the  posterior  face  of  the  head  of  the  radius ;  a  fall  upon  the 
hand  with  the  forearm  extended  and  pronated ;  extreme  pronation  of 
the  forearm ;  or,  according  to  Denuc^,  a  blow  upon  the  inside  of  the 
elbow,  which  is  equivalent  to  a  violent  adduction  of  the  forearm. 

In  children,  and  especially  in  those  of  a  strumous  habit,  whose 
ligaments  are  feeble,  a  subluxation  forwards,  or  even  a  complete  luxa- 
tion, is  occasionally  produced  by  being  lifted  suddenly  from  the  floor 
by  the  hand,  or  by  an  attempt  to  sustain  the  child  when  he  is  about 
to  fall.  I  have  seen  examples  of  this  dislocation  produced  in  this 
way.  Batchelder,^  Sylvester,-  Goyrand,^  and  many  other  surgeons, 
have  mentioned  similar  cases.  In  the  case  of  Lydia  Merton,  four  years 
old,  brought  to  me  in  May,  1868,  the  dislocation  was  caused  by  hold- 
ing on  by  the  hands  after  having  fallen  from  a  swing. 

Dr.  Krackowizer  related  to  the  New  York  Academy,  in  1856,  a 
case  of  complete  dislocation  forwards,  produced,  as  was  supposed,  in 

'  New  York  Jonrn.  Med.,  May,18r)6,  p.  333. 

2  Amer.  Journ.  ]Mecl.  Sci..  voL  xxxi.  p.  206,  Jan.  1843. 

3  Ibid. ,  vol.  xxxii.  p.  228,  July,  18i3. 


580         DISLOCATIONS    OF    THE    HEAD    OF    THE    RADIUS. 


Fis.  251. 


the  act  of  turning  the  child  in  delivery.     The  arm  was  ecchymosed, 

and  the  dislocation  was  very  distinct.^ 

Pathological  Anatomy —1^\\Q  head  of  the  radius  is  carried  forwards 

upon  the  humerus,  and  generally  a  little  outwards.     In  the  case  of 

Lydia  Merton,  already  mentioned, 
the  head  of  the  radius,  on  the  nine- 
ty-fourth day  after  the  accident, 
was  nearly  in  the  centre  of  the 
humerus.  The  anterior  and  ex- 
ternal lateral  ligaments,  with  the 
annular,  are  in  most  cases  more  or 
less  broken.  Sometimes  the  ante- 
rior and  external  lateral  are  alone 
broken,  the  annular  ligament  being 
then  sufficiently  stretched  to  allow 
of  the  complete  dislocation  ;  or  the 
anterior  and  annular  having  given 
way,  the  external  lateral  may  re- 
main intact. 

Symptoms. — The  head  of  the 
radius  can  in  general  be  distinctly 
felt  in  its  new  situation,  rotating 
under  the  finger  when  the  hand  is 
pronated  and  supinated ;  we  may 
sometimes  also  recognize  a  depres- 
sion corresponding  to  its  natural 
situation,   behind  and    below  the 

Head  of  radius  forwards.     Anatomical  relations.       llttlc    head    01    the    humCrUS.        i  be 

external  border  of  the  forearm  is 
slightly  shortened,  and  the  arm  inclines  unnaturally  outwards.  The 
tendon  of  the  biceps  is  relaxed.  The  forearm  is  generally  pronated, 
sometimes  it  is  in  a  position  midway  between  supination  and  prona- 
tion, but  I  have  never  seen  it  supinated.  I  have  particularly  noticed 
this  fact  in  my  report  made  to  the  New  York  State  Medical  Society 
in  1855 ;  and  Denucd,  who  has  also  examined  these  cases  carefully, 
affirms  that  it  is  seldom  supinated,  notwithstanding  the  general  state- 
ments of  surgeons  to  the  contrary. 

The  arm  is  usually  a  little  flexed,  and  cannot  be  perfectly  extended 
without  causing  pain.  In  some  cases,  especially  when  the  dislocation 
has  existed  for  a  considerable  length  of  time,  the  arm  is  capable  of 
extreme  and  unnatural  extension..  This  was  the  case  with  Lydia 
Merton.  There  is  usually  preternatural  lateral  motion;  but,  except 
in  old  cases,  the  forearm  cannot  be  flexed  upon  the  arm  beyond  a 
right  angle. 

Progyiosis. — Denuc^  says  :  "  The  reduction  is  often  impossible ;  more 
frequently  still,  difficult  to  maintain."  In  proof  of  which  he  refers  to 
the  observations  of  Danyau  and  Robert.  In  the  case  of  recent  luxa- 
tion related  by  Robert,  it  was  found  impossible  to  maintain  a  reduc- 


'  Krackowizer,  New  York  Journ.  Med.,  March,  1857,  p.  363. 


DISLOCATIOlSr    OF    HEAD    OF    RADIUS    FORWARDS.       581 


Fin;.  252. 


tion  which  he  thought  he  had  several  times  accomplished,  and  he 
believed  that  the  difficulty  consisted  in  a  portion  of  the  torn  annular 
ligament  having  become  entangled  between  the  head  of  the  radius  and 
the  condyle  of  the  humerus.^ 

Sir  Astley  Cooper  was  unable  to  accomplish  the  reduction  in  two 
recent  cases;  and  of  the  six  cases  which  came  under  his  immediate 
observation,  only  two  were  ever  re- 
duced. In  Bransby  Cooper's  edition 
of  Sir  Astley's  work,  other  similar 
examples  of  non-reduction  are  re- 
lated. 

Malgaigne  says  that  in  a  collec- 
tion of  twenty-five  cases  which  he 
has  made,  the  accident  was  unrecog- 
nized or  neglected  in  six,  and  in- 
effectual efforts  at  reduction  had  been 
made  in  eleven;  so  that  only  eight 
of  the  whole  number  were  reduced. 

I  have  myself  met  with  six  of 
these  simple  dislocations  which  were 
not  reduced,  three  of  which,  however, 
had  not  been  recognized,  and  no 
attempts  at  reduction  had  ever  been 
made;  one  had  been  treated  by  an 
empiric,  Sweet,  a  "natural  bone-set- 
ter," but  without  success ;  one  had 
been  reduced,  but  it  had  become 
reluxated,  and  in  the  remaining 
example  I  was  myself  unable  to 
reduce  the  dislocation  on  the  seventh 
day. 

The  following  are  brief  notes  of 
four  of  these  cases : — 

A  young  man,  set.  23,  presented 
himself  at  my  office,  to  whom  the 

accident  had  occurred  about  one  year  before.  The  surgeon  who  was 
first  called  did  not  recognize  the  dislocation,  and  no  attempt  had  ever 
been  made  to  replace  the  bones.  The  forearm  was  forcibly  prouated 
and  could  not  be  supinated,  but  he  could  extend  it  completely,  and 
flex  it  somewhat  beyond  a  right  angle.  It  was  strong,  and  nearly  as 
useful  as  before. 

H.  II.  B.,  set.  6 ;  dislocation  produced  by  a  fall  upon  the  elbow. 
The  surgeon  who  was  called  did  not  detect  the  nature  of  the  injury. 
Eighteen  years  after,  I  found  the  head  of  the  radius  lying  in  front  of 
the  old  socket,  having  formed  a  new  socket  in  which  it  moved  freely. 
From  the  elbow  to  the  hand  the  arm  inclined  outwards,  or  to  the 
radial  side;  pronation  and  supination  were  perfect.     He  could  flex 


Head  of  radius  forwards, 
ance  of  limb. 


External  appear 


'  Memoire  sur  les  Luxations  du  Coude,  par  Paul  Dcuuce.     Paris,  1854. 


582         DISLOCATIONS    OF    THE    HEAD    OF    THE    RADIUS. 

the  arm  to  an  acute  angle,  but  not  so  completely  as  the  other.  The 
arm  was  as  strong  as  the  other,  but  it  was  frequently  hurt  by  lifting. 

Ira  E.  Irish,  £et.  12.  "  Sweet"  was  at  first  employed,  but  f\uled  to 
reduce  it.  Thirty-nine  years  after,  when  Mr.  Irish  was  fifty-one  years 
old,  I  examined  the  arm.  He  could  not  flex  the  forearm  upon  the 
arm  beyond  a  right  angle ;  and  when  the  attempt  was  made,  the  radius 
struck  against  the  humerus.  Complete  supination  was  impossible. 
The  arm  was  as  strong  as  the  other,  except  in  raising  a  weight  above 
his  head.     Occasionally  he  was  annoyed  with  slight  pains  in  this  limb. 

Urias  Lett,  a  colored  barber  of  Buffalo,  aged  forty-eight  years,  was 
thrown  from  a  carriage,  producing  dislocation  of  the  right  radius,  and 
severely  bruising  the  elbow-joint.  He  drove  a  couple  of  spirited 
horses  several  miles  after  the  accident,  and  did  not  see  Dr.  K.,  a  highly 
accomplished  young  surgeon,  until  six  hours  had  elapsed.  The  elbow 
was  then  much  swollen,  and  exquisitely  tender,  and  Lett  would  not 
permit  much  if  any  examination,  to  enable  Dr.  K.  to  determine  his 
condition.  The  doctor  applied  simple  dressings,  and  the  next  day  re- 
quested me  to  see  him.  The  whole  arm  was  then  swollen  and  tender, 
and  very  little  examination  was  admissible.  The  dressings  were, 
therefore,  not  completely  removed,  but  only  laid  open  sufficiently  to 
enable  us  to  see  the  joint.  We  suspected  a  forward  luxation  of  the 
head  of  the  radius,  but  could  not  positively  determine  the  point — the 
patient  not  permitting  any  kind  or  degree  of  manipulation.  We 
decided,  therefore,  to  wait  a  few  days  until  the  inflammation  had 
somewhat  abated,  and  then,  if  the  existence  of  a  dislocation  was  ascer- 
tained, to  attempt  its  reduction.  On  the  seventh  day  the  swelling  had 
measurably  subsided,  and  the  diagnosis  became  satisfactory.  We 
immediately  placed  him  under  the  complete  influence  of  chloroform, 
and  made  long-continued  and  violent  efforts  at  reduction,  but  without 
success.  Severe  inflammation  again  followed  these  efforts,  and  Lett 
would  never  consent  to  another  trial.  After  four  years,  I  find  the 
bone  still  out.  He  can  flex  the  forearm  upon  the  arm  almost  as  far 
as  he  can  the  opposite  limb ;  he  can  carry  it  nearly  to  his  mouth  ;  the 
head  of  the  radius  sliding  off  upon  the  outer  face  of  the  humerus,  and 
not  resting  plumply  against  it;  indeed,  the  radius  seems  to  have  been 
gradually  pushed  outwards  as  well  as  forwards.  The  hand  is  forcibly 
pronated,  and  cannot  be  supinated.  The  attempt  to  supine  produces 
a  click  in  the  neighborhood  of  the  head  of  the  radius,  as  if  it  struck 
against  a  bone.  The  arm  is  as  strong  as  the  other,  and  not  wasted. 
He  has  constantly  pursued  his  occupation  as  a  barber,  after  only  a  few 
weeks'  confinement. 

If  the  dislocation  is  accompanied  with  a  fracture  of  the  ulna,  unless 
the  fracture  is  transverse  or  incomplete,  reduction  is  not  generally 
accomplished.  When  speaking  of  fractures  of  the  shaft  of  the  ulna,  I 
have  related  several  examples  illustrative  of  this  remark.  Norris 
has  made  the  same  observation.^  I  have,  however,  three  times  met 
with  this  accident  thus  complicated  in  children,  in  the  treatment  of 
which  a  much  better  result  has  been  obtained.     In  the  first  example, 

'  Norris,  Amer.  Joiirn.  Med.  Sci.,  vol.  xxxi.  p.  21. 


DISLOCATION    OF    HEAD    OF    RADIUS    FORWARDS.        583 

a  lad  aged  nine  years  had  broken  the  ulna  in  its  upper  third  and  dis- 
located the  radius  forwards.  Dr.  White,  of  Buffalo,  and  myself  were 
in  immediate  attendance.  Both  the  fracture  and  dislocation  were 
easily  reduced,  and  in  a  few  weeks  the  limb  was  sound  and  perfect, 
except  that  a  slight  fulness  remained  in  front  of  the  head  of  the  radius, 
and  this  continued  for  several  years.  In  the  second  example,  a  lad,  of 
the  same  age  as  the  other,  was  treated  by  Dr.  Austin  Flint  and  my- 
self We  reduced  both  the  fracture  and  the  dislocation  by  extending 
the  arm  from  the  wrist,  while  at  the  same  moment  pressure  was  made 
upon  the  head  of  the  radius  from  before  backwards.  A  right-angled 
splint  was  applied  and  continued  during  a  period  of  four  weeks,  being 
removed  daily  for  the  purpose  of  giving  to  the  joint  gentle,  passive 
motion,  &c.  After  this  the  arm  was  permitted  to  straighten  gradually, 
and  at  the  end  of  a  month  more  the  joint  was  moving  freely,  and  with 
no  degree  of  displacement  at  the  point  of  fracture  or  dislocation. 

It  is  quite  probable  that  in  each  of  the  above  cases  the  separation 
was  not  complete,  although  crepitus  was  distinct,  and  the  displacement 
of  the  broken  ends  was  very  marked.  In  the  following  case  the  frac- 
ture was  certainly  incomplete: — 

Elizabeth  Carmody,  set.  4,  was  brought  to  me,  August  6,  1851,  with 
a  fracture  of  the  ulna,  two  inches  below  its  upper  end,  the  fragments 
being  inclined  backwards,  while  the  radius  was  dislocated  forwards. 
Both  bones  were  easily  replaced,  and  the  functions  of  the  arm  were 
soon  completely  restored.^ 

Where  the  restoration  has  been  promptly  effected  and  maintained 
steadily,  the  motions  of  the  joint  are  soon  restored ;  but  in  one  case 
the  head  of  the  radius  has  been  found  to  play  very  freely  and  loosely 
after  the  lapse  of  two  years,  and  in  others  it  has  remained  slightly 
prominent  in  front,  as  if  it  was  a  little  in  advance  of  its  socket. 

Treatment. — Extension  and  counter-extension  should  be  made  in  the 
direction  in  which  we  already  find  the  limb,  namely,  with  the  forearm 
slightly  bent  upon  the  arm,  while  at  the  same  moment  the  surgeon 
should  seize  the  elbow  with  his  hands,  and  press  the  head  of  the  radius 
back  with  his  two  thumbs. 

Other  methods  will  often  succeed  ;  but  by  this  we  relax  the  biceps, 
and  put  the  parts  in  the  best  position  to  accomplish  the  reduction 
easily  and  promptly.  Sir  Astley  directed  to  supine  the  forearm  while 
the  extension  was  being  made  from  the  hand,  but  Denucd  prefers  that 
the  forearm  should  be  in  a  position  of  pronation. 

After  the  reduction  is  effected  it  is  never  safe  to  straisrhten  the  arm 
completely  at  once,  nor  indeed  for  some  weeks ;  not  until  the  ligaments 
have  been  sufficiently  restored  to  resist  the  action  of  the  biceps.  The 
arm  must  therefore  be  flexed  and  placed  in  a  sling,  or,  if  the  radius  is 
disposed  to  become  reluxated,  a  right-angled  splint  ought  to  be  placed 
upon  the  back  of  the  arm  and  forearm,  and,  by  the  aid  of  a  compress 
and  roller,  an  attempt  should  be  made  to  retain  it  in  place. 

Nor  will  it  be  found  safe  at  any  period  to  compel  the  arm  by  force 

'  This  case  was  erroneously  reported  to  the  N.  Y.  State  Medical  Society  as  an 
example  of  fracture  of  the  radius,  with  dislocation. 


584        DISLOCATIONS    OF    THE    HEAD    OF    THE    RADIUS. 

to  resume  the  straight  position,  since  this  bone,  when  it  has  once  been 
dislocated,  will  for  a  long  time  be  liable  to  luxation. 

A  boy,  aged  about  four  years,  was  presented  at  my  clinic  by  his 
father,  having  a  forward  dislocation  of  the  head  of  the  radius.  The 
dislocation  had  existed  several  months.  The  father's  purpose  in  bring- 
ing the  child  was  to  ascertain  whether  he  could  not  claim  damages 
for  malpractice.  The  account  which  he  gave  was  as  follows:  The 
surgeon  called  it  a  dislocation  forwards,  and  pretended  to  reduce  it. 
A  right-angled  splint  was  applied  with  a  roller.  At  the  end  of  three 
weeks  the  father  removed  the  splint,  but  did  not  discover  anything  out 
of  place.  Finding,  however,  that  the  elbow  was  stiff"  he  took  measures 
to  straighten  it  forcibly.  In  a  few  days  he  discovered  the  head  of  the 
bone  out  of  place,  and  so  it  has  remained  ever  since. 

I  explained  to  him  that  there  was  much  reason  to  suppose  that  the 
surgeon  had  properly  reduced  the  dislocation,  and  that  he  had  himself 
reproduced  the  accident,  by  straightening  the  arm,  through  the  action 
of  the  biceps  upon  the  upper  end  of  the  radius.  The  father  declined 
any  further  surgical  interference,  and  no  prosecution  has  followed. 

The  late  Dr.  Batchelder,  of  this  city,  in  a  very  excellent  paper  on 
dislocations  of  the  head  of  the  radius,  has  described  a  method  of 
reduction  suggested  to  him  first  by  Dr.  Goodhue,  of  Chester,  Vermont, 
and  which  he  had  himself  found  more  successful  than  any  other 
method ;  indeed,  he  says  it  never  fails,  yet  he  does  not  inform  us  in 
precisely  how  many  cases  he  had  made  the  trial.  The  plan  suggested 
by  Dr.  Goodhue  consists  essentially  in  first  making  extension  from 
the  hand,  and  pressing  at  the  same  time  downwards  and  backwards 
upon  the  head  of  the  radius  until  it  has  descended  to  a  level  with  the 
articulating  surface  of  the  humerus.  As  soon  as  this  is  accomplished, 
the  forearm  is  to  be  suddenly  flexed  upon  the  arm  in  such  a  direction 
as  that  the  hand  shall  pass  outside  of  the  shoulder ;  at  the  same 
moment,  also,  the  pressure  must  be  continued  vigorously  upon  the 
head  of  the  radius.^ 

§  2.  Dislocation  of  the  Head  of  the  Radius  Backwards. 

Denuc^  has  collected  fourteen  examples  of  this  luxation  ;  but  Mal- 
gaigne,  who  rejects  a  portion  of  the  cases,  and  adds  one  or  two  more, 
admits  only  twelve.  In  addition  to  those  mentioned  by  these  two 
writers,  I  have  found  recorded,  or  incidentally  noticed,  one  by  May,^ 
one  by  Bransby  Cooper,^  one  by  Lawrence,*  one  by  Liston,*  two  by 
Case,^  two  by  Gibson,^  one  by  Parker,*  three  by  Markoe,^  and  to  these 
my  own  observations  have  added  four  more,  in  all  twenty-eight  sup- 
posed examples. 

1  Goodhue,  New  York  Journ.  of  Med.,  May,  1856,  p.  333. 

2  May,  Sir  Astley  Cooper  on  Dislocations,  &c.,  by  B.  Cooper,  op.  cit.,  p.  403. 

3  B.  Cooper,  ibid.,  p.  404.  *  Lawrence,  Pirrie's  System  of  Surgery,  p.  359. 

5  Liston,  Practical  Surgery,  p.  88. 

6  Case,  Amer.  Journ.  of  Med.  Sci.,  vol.  vi.  p.  254,  from  11th  No.  of  Provincial 
Med.  Gazette. 

'  Gibson,  Institutes  and  Practice  of  Surgery,  6th  ed.,  vol.  i.  p.  379. 
^  Parker,  New  York  Journ.  of  Med.,  March,  1852,  p.  188. 
s  Markoe,  ibid.,  May,  1855,  p.  382. 


DISLOCATION    OF    HEAD    OF    RADIUS    BACKWARDS.      585 

Of  the  examples  brought  under  my  own  notice  I  have  already  in 
the  preceding  section  affirmed  that  two  of  them  were  accompanied 
with  fracture,  and  I  am  not  entirely  certain  but  that  they  all  were, 
Markoe,  of  New  York,  whom  we  have  mentioned  as  having  reported 
three  cases,  found  in  each  case  a  fracture  of  the  internal  condyle  of 
the  humerus,  and,  after  an  examination  of  a  number  of  the  reported 
examples,  he  does  not  find  any  evidence  that  this  dislocation  ever 
occurs  as  a  simple  uncomplicated  accident.  I  am  unable  to  complete 
the  critical  analysis  which  Dr.  Markoe  has  undertaken  ;  yet  I  confess 
that,  so  far  as  I  have  been  able  to  do  so,  the  testimony  strongly  con- 
firms his  conclusion.  While  I  am  prepared  to  admit  the  possibility 
of  the  luxation  without  either  a  fracture  of  the  lower  end  of  the 
humerus  or  of  the  ulna,  I  have  found  no  written  account  of  any  case, 
nor  have  I  seen  an  example,  which  was  absolutely  conclusive. 

The  example  reported  by  Parker  as  having  occurred  in  the  practice 
of  N.  K.  Freeman,  of  this  city,  is  one  of  the  few  which  seems  to  admit 
of  but  very  little  doubt. 

In  July,  1850,  Dr.  Freeman  was  called  to  see  a  gentleman,  set.  37, 
who  was  seriously  injured  by  jumping  from  the  railroad  cars  while 
they  were  in  motion,  and  found  a  backward  luxation  of  the  head  of 
the  radius  of  the  right  arm.  "The  symptoms,"  says  Dr.  Freeman, 
"were  marked;  the  hand  and  forearm  were  prone,  and  the  attempt  to 
place  them  in  the  supine  position  caused  great  pain ;  while  the  head  of 
the  radius  formed  a  considerable  projection  posterior  to  the  external 
condyle  of  the  humerus,  where  the  cavity  on  its  extremity  could  be  dis- 
tinctly felt.  Assisted  by  Dr.  Walsh,  of  Fordham,  who  firmly  grasped 
the  humerus,  I  was  enabled  to  reduce  it  by  extending  the  forearm  and 
flexing  it  upon  the  arm,  at  the  same  time  pronating  the  hand,  and 
pressing  forwards  the  head  of  the  radius  with  my  thumb.  After  the 
reduction  was  eflected,  I  requested  Dr.  Walsh  to  examine  it;  when, 
upon  slight  extension  being  made  upon  the  forearm,  with  supination 
of  the  hand,  the  bone  was  again  dislocated.  I  immediately  reduced 
it  in  the  same  manner  as  before,  and  directed  the  patient  to  keep  the 
forearm  flexed  and  the  hand  prone,  and,  laying  it  upon  a  pillow,  apply 
cold  water.  He  complained  of  severe  pain  for  two  days,  which  gradu- 
ally subsided,  and  on  the  fourth  day  he  was  able  to  move  and  extend 
the  forearm." 

Causes. — A  direct  blow  upon  the  front  and  upper  part  of  the  radius; 
a  fall  upon  the  elbow,  or  upon  the  hand;  a  violent  effort  to  supinate 
the  forearm  while  it  is  grasped  and  held  firmly  in  a  state  of  pronation; 
probably,  also,  sometimes  it  is  occasioned  by  a  twisting  of  the  arm  in 
machinery,  &c. 

Pathological  Anatomy. — In  the  only  example  of  which  a  dissection 
has  been  made,  reported  by  Sir  Astley  Cooper,  "the  coronary  liga- 
ment was  found  to  be  torn  through  at  'its  forepart,  and  the  oblique 
had  given  way.  The  capsular  ligament  was  partially  torn,  and  the 
head  would  have  receded  much  more,  had  it  not  been  supported  by 
the  fascia  which  extends  over  the  muscles  of  the  forearm."  The  head 
of  the  radius  was  thrown  behind  the  external  condyle  of  the  humerus, 
and  rather  to  the  outer  side.  This  was  an  ancient  luxation  found  in 
38 


586        DISLOCATIONS    OF    THE    HEAD    OF    THE    EADIUS. 


Fifif.  353. 


tbe  dissecting-room  of  St.  Thomas's  Hospital,  and  the  accompanying 
drawing  is  copied  from  the  sketch  made  at  the  time. 

If  the  luxation  is  not  complete,  as  occasionally  happens  with  chil- 
dren, the  annular  ligament  may  not  be  torn. 

Symptoms. — The  head  of  the  bone  is  felt  rotating  behind  the  outer 
condyle,  and  a  depression  exists  corresponding  to  its  original  position. 
The  forearm  is  slightly  flexed  and  prone;  and  the 
whole  arm  is  deflected  outwards  from  the  elbow 
downwards ;  flexion  and  extension  are  difficult,  while 
supination  is  impossible. 

Treatment. — Most  surgeons  have  agreed  that  while 
extension  and  counter-extension  are  being  made,  the 
forearm  should  be  forcibly  supinated.  At  the  same 
time,  also,  the  head  of  the  radius  must  be  strongly 
pushed  forwards.  Martin  recommends  •  to  extend 
forcibly,  and  then  suddenly  flex  the  arm,  in  a  manner 
very  similar  to  the  plan  recommended  by  Batchelder 
in  dislocations  forwards.  In  Dr.  Freeman's  case,  just 
quoted,  the  reduction  was  effected  while  the  forearm 
was  pronated,  and  supination  seemed  to  throw  it 
again  out  of  place. 

According  to  Markoe,  where  the  accident  is  com- 
plicated with  a  fracture  of  the  inner  condyle,  when 
the  reduction  is  accomplished  the  arm  should  be 
placed  in  a  position  about  ten  degrees  less  than  a 
right  angle,  and  supported  by  a  splint  with  band- 
ages, &c. 

If  the  dislocation  is  simple,  however,  I  can  see  no 
objections  to  its  being  nearly  or  quite  extended,  since 
in  this  dislocation  the  action  of  the  biceps  would  only  tend  to  retain 
the  head  of  tbe  radius  in  place. 


Dislocation  of  the 
head  of  the  radius 
backwards. 


§  3.  Dislocation  of  the  Head  of  the  Radius  Outwards. 

Denuce  has  collected  four  examples  of  this  accident,  unaccompanied 
with  a  fracture,  and  he  proceeds  to  speak  of  it  as  a  distinct  form  of 
dislocation.  In  two  of  the  examples,  however,  mentioned  by  him,  it 
was  consecutive  upon  a  forward  luxation,  and  I  have  several  times 
seen  the  head  of  the  radius  very  much  inclined  outwards  in  what  are 
properly  termed  forward  dislocations.  For  these  reasons  it  is  not  very 
plain  to  me  that  we  ought  to  consider  this  as  a  distinct  form  of  pri- 
mary dislocation,  but  rather  as  a  consecutive  luxation,  or  at  least  as 
only  a  modification  of  the  forward  or  backward  luxation.  Indeed,  I 
think  the  radius  never  will  be  found  thrown  directly  outwards,  but 
always  in  a  direction  inclining  forwards  or  backwards. 

Parker,  of  this  city,  mentions  a  case  which  came  under  his  notice, 
in  a  child  four  years  old,  who,  six  weeks  before,  had  fallen  down  stairs 
"  backwardly,  with  the  right  arm  twisted  behind  the  back,  in  such  a 
position  that  the  whole  weight  of  her  body  came  upon  her  arm."  No 
attempt  was  ever  made  to  reduce  tbe  bone,  and  the  head  of  the  radius 


DISLOCATIOJS^S    OF    UPPER    EXD    OF    ULNA    BACKWARDS.      587 

continued  to  project  externally.  By  pressure  it  was  easily  reduced, 
but  became  immediately  displaced  when  the  forearm  was  either  flexed 
or  extended.  The  motions  of  the  joint  were  completely  restored.  Dr. 
Parker  recommended  no  treatment.^ 


CHAPTER    VIII. 

DISLOCATIONS  OF  THE  UPPER  END  OF  THE   ULNA  BACKWARDS. 

This  accident,  the  existence  of  which,  as  a  simple  luxation,  is  placed 
beyond  doubt,  has  nevertheless  been  described  so  variously,  and  often 
indefinitely,  that  it  is  impossible  to  declare  its  history,  ex-6ept  in  a  few 
points,  with  any  degree  of  accuracy.  No  doubt  many  of  the  cases 
which  have  been  reported  were  examples  only  of  a  subluxation  of 
both  radius  and  ulna  backwards.  In  other  cases,  the  radius  or  the 
external  condyle  of  the  humerus  being  broken,  the  ulna  has  been  ac- 
tually displaced,  not  only  backwards,  but  upwards;  indeed,  it  is  very 
certain  that  without  either  a  luxation  of  the  radius,  or  a  fracture  with 
displacement  of  the  external  condyle  of  the  humerus,  or  a  fracture  or 
bending  of  the  radius,  an  upward  displacement  of  the  ulna,  to  the 
degree  represented  by  the  reporters  of  these  cases,  could  never  have 
occurred.  The  example  mentioned  by  Sir  Astley  Cooper,  and  of  which 
a  dissection  was  made,  is  plainly  a  case  of  subluxation  of  both  bones ; 
or  if  the  luxation  of  the  ulna  may  be  regarded  as  having  been  com- 
plete, the  head  of  the  radius  was  also  displaced  more  or  less  upwards 
from  its  original  socket,  a  new  socket.  Sir  Astley  himself  informs 
us,  having  been  formed  for  its  reception,  upon  the  external  condyle. 
But  this  is  the  only  example,  the  actual  condition  of  which  has  been 
proven  by  an  autopsy. 

Nevertheless,  it  seems  probable  that  a  simple  luxation  or  subluxa- 
tion of  the  ulna  backwards  may  occur  without  either  of  the  above- 

Fior.  254. 


Dislocation  of  the  upper  end  of  the  ulna  backwards. 

mentioned  complications,  and  that,  to  the  extent  of  a  few  lines,  it  may 
be  made  to  pass  upwards  upon    the  back  of  the   humerus,  by  the 

1  Parker,  New  York  Journ.  Med.,  March,  1853,  p.  189. 


588  DISLOCATIONS    OF    THE    RADIUS    AND    ULNA. 

falling  of  the  forearm  to  the  ulnar  side;  in  which  case  the  character 
of  the  accident  would  probably  be  recognized  by  the  projection  of 
the  olecranon  process,  while  the  head  of  the  radius  might  be  felt 
moving  in  its  socket— by  the  partial  flexion  and  complete  pronation 
of  the  forearm,  and  by  the  general  immobility  of  the  joint.  In  a  case 
reported  by  Dr.  Waterman,  caused  by  a  fall  on  the  hand,  the  arm  was 
at  a  right  angle,  and  pronated.* 

Its  reduction  ought  to  be  accomplished  easily,  one  would  think,  by 
the  same  measures  which  have  been  found  successful  in  reducing  a 
dislocation  of  both  bones  backwards;  but  in  Waterman's  case  this 
method  failed,  and  the  reduction  was  promptly  eflected  by  bending 
the  forearm  forcibly  back. 

Pirrie  says  that  in  a  case  occurring  in  the  practice  of  Mr.  Gosset, 
in  which  the  coronoid  process  rested  on  the  internal  condyle,  and  the 
pain  on  bending  the  arm  was  insupportable,  owing,  it  was  supposed, 
to  the  pressure  of  the  coronoid  process  against  the  ulnar  nerve,  "  re- 
duction was  accomplished  by  extension  and  counter-extension  applied 
by  two  persons  pulling  in  opposite  directions,  and  by  the  pressure  of 
the  olecranon  process  downwards  and  outwards,  while  the  forearm 
was  suddenly  flexed."^ 


i 


CHAPTER    IX. 

DISLOCATIONS  OF  THE  RADIUS  AND  ULNA  (FOREARM  AT 
THE  ELBOW-JOINT). 

The  radius  and  ulna  may  be  dislocated  at  the  elbow-joint  back- 
wards; laterally,  that  is,  either  inwards  or  outwards;  and  forwards. 

§  1.  Dislocations  of  the  Radius  and  Ulna  Backwards. 

Causes. — In  fifty-six  cases  observed  by  me,  the  average  age  is 
about  twenty  years;  the  youngest  being  four  years  old,  and  the 
oldest  fifty-three.  Twenty-two  of  this  number  occurred  in  children 
under  fourteen  years  of  age. 

Generally  the  dislocation  has  been  produced  by  a  fall  upon  the 
palm  of  the  hand,  as  when  in  running  a  person  has  fallen  forwards 
with  the  forearm  extended  in  front  of  the  body,  or  he  may  have  fallen 
from  a  height;  once  I  have  known  it  produced  by  a  blow  received 
upon  the  back  and  lower  part  of  the  humerus;  and  in  several  in- 
stances the  patients  have  declared  that  they  had  fallen  upon  the  elbow  ; 
it  is  produced,  occasionally,  by  twisting  the  forearm  violently,  as  when 
the  limb  has  been  caught  and  wrenched  about  by  machinery,  by  a 
blow  upon  the  front  and  upper  part  of  the  forearm,  and  by  forced 
flexion. 

'  Boston  Med.  and  Surg.  .Tonm.,  vol.  iv..  new  series. 
^  Gosset,  Pirrie' s  Surg.,  Amer.  ed.,  p.  259. 


DISLOCATION    OF    EADIUS    AND    ULNA    BACKWARDS.      589 

Pathology. — The  radius  and  ulna  are  not  only  carried  backwards 
behind  the  articulating  surface  of  the  humerus,  but  they  are  also, 
through  the  action  of  the  triceps,  almost  always  drawn  more  or  less 
upwards,  so  that  often  the  corouoid  process  of  the  ulna  rests  in  the 
olecranon  fossa.  In  some  cases  it  has  been 
known   to    mount   even    higher,   while   in  Fig.  255. 

others  it  is  arrested  short  of  this  point.  The 
radius  still  retaining  its  relative  position  to 
the  ulna,  lies  upon  the  back  of  the  humerus, 
or  rather  upon  the  posterior  margin  of  its 
articulating  surface. 

The  anterior  and  two  lateral  ligaments 
are  generally  more  or  less  completely  torn 
asunder ;  but  the  posterior  ligament  and  the 
annular  do  not  usually  suffer  disruption. 

The  biceps  muscle  is  drawn  over  the 
lower  articulating  surface  of  the  humerus, 
but  is  in  a  condition  of  only  moderate  ten- 
sion, while  the  brachialis  anticus  is  forcibly 

stretched,  or  even  torn.  BlslocaUon  of  the  radius  and  ulna 

The  median  nerve  is  also  pressed  upon    backwards. 
in  front  by  the  humerus,  and  the  ulnar  is  occa- 
sionally painfully  stretched  over  the  projecting  extremity  of  the  ulna 
from  behind. 

Symptoms. — Sir  Astley  Cooper  does  not  mention  particularly  the 
position  of  the  arm  as  to  flexion  or  extension,  except  to  say  that  "  the 
flexion  of  the  joint  is  in  a  great  degree  lost ;  nor,  in  his  original  work, 
published  in  London  in  1823,  is  there  any  illustration  accompanying 
the  text  to  indicate  in  what  position  he  had  usually  seen  the  limb ; 
but  in  the  later  editions,  edited  by  Mr.  Bransby  Cooper,  is  found  a 
drawing  which  represents  the  forearm  at  a  right  angle  with  the  arm. 
It  is  very  certain  that  Sir  Astley  never  sanctioned  this  error  by  any- 
thing which  he  had  written  or  communicated  to  others.  It  is  very 
certain,  I  say,  because  the  fact  that  it  seldom,  if  ever,  occupies  this 
position,  could  not  have  escaped  the  notice  of  one  whose  experience 
was  so  large,  and  whose  habits  of  observation  were  generally  so  accu- 
rate. The  truth  is  that  it  is  almost  constantly  found  only  slightly 
flexed,  or  forming  an  angle  in  front  of  about  120°. 

This  fact  is  especially  noticed  in  my  records  twenty-six  times,  and 
if  it  had  ever  been  found  in  any  other  position,  it  would  certainly 
have  been  stated.  Once,  where  the  dislocation  was  accompanied  with 
a  fracture  of  the  outer  condyle  of  the  humerus,  the  arm  was  at  first 
straight,  a  position  in  which  it  is  said  to  be  found  occasionally  with 
children ;  and  in  the  case  of  a  patient  admitted  to  Bellevue  Hospital, 
on  the  14th  of  December,  1864,  the  dislocation  having  existed  thirty- 
one  days,  but  unaccompanied  with  a  fracture,  I  found  the  arm  straight, 
and  there  existed  also  a  preternatural  lateral  mobility  of  the  elbow- 
joint;  but  never,  in  any  case  of  a  recent  dislocation,  and  but  once  in 
an  old  dislocation,  have  I  found  it  flexed  to  a  right  angle;  yet  I  will 
not  deny  that  such  unusual  phenomena  are  possible  in  recent  disloca- 


590  DISLOCATIONS    OF    THE    RADIUS    AND    ULNA. 

tions;  indeed,  it  is  certain  that  they  have  occasionally  been  presented, 
but  they  must  be  regarded  as  only  exceptional,  and  as  by  no  means 
diagnostic  of  this  accident. 

Sir  Astley  Cooper  and  Miller  declare  that  in  this  dislocation  the 
forearm  is  usually  supinated;  Pirrie  says  "the  hand  is  between  prona- 
tion and  supination,  but  more  inclined  to  the  latter;"  Desault  thinks  it 
is  sometimes  in  supination  and  sometimes  in  pronation ;  Denuce  con- 
cludes that  it  will  occupy  that  position,  whatever  it  may  be,  in  which 
the  force  of  the  blow  ha"s  thrown  it;  while  by  most  surgical  writers 
no  allusion  is  made  to  the  position  of  the  forearm  in  reference  to  pro- 
nation or  supination.  For  myself,  I  can  only  say  that  I  have  found 
the  forearm  and  hand  almost  constantly  in  a  position  of  moderate  but 
positive  pronation,  and  I  am  compelled  to  regard  it,  therefore,  as  one 
of  the  usual  signs  of  a  backward  dislocation  of  these  bones. 

The  limb  can  be  neither  flexed  nor  extended  without  force,  and 
such  motion  is  almost  always  accompanied  with  pain.  It  is,  however, 
possible  in  most  cases  to  give  to  the  arm  a  slight  lateral  motion,  such 
as  does  not  belong  to  it  in  its  natural  condition. 

In  front,  and  deep  in  the  fold  of  the  elbow,  is  felt  the  lower  end  of 
the  humerus,  forming  a  hard,  broad,  and  somewhat  irregular  projec- 
tion, over  which  the  integuments  and  muscles  are  swollen,  and  tender 
to  pressure.  Behind,  the  head  of  the  radius  may  be  felt,  when  not 
much  tumefaction  exists,  rotating  or  moving  under  the  finger  when 
the  forearm  is  supinated  and  pronated ;  while  the  olecranon  process 
projects  strongly  backwards  and  upwards.  If  now  we  flex  the  arm 
slightly,  this  projection  of  the  olecranon  process  will  be  sensibly  in- 
creased;  but  if  an  attempt  is  made  to  straighten  the  arm,  it  will  be 
diminished,  the  reverse  of  what  we  have  seen  to  happen  in  cases  of 
fracture  of  the  lower  end  of  the  humerus  (at  the  base  of  the  condyles). 
This  circumstance  becomes,  therefore,  an  important  diagnostic  mark 
between  these  two  accidents. 

The  relation  of  the  olecranon  process,  also,  to  the  condyles  is  changed, 
and  the  upper  end  of  this  process,  instead  of  being  a  little  below  the 
internal  condyle,  as  it  would  be  naturally  when  the  arm  is  slightly 
flexed,  is  found  generally  carried  upwards  toward  the  shoulder,  from 
half  an  inch  to  one  inch  or  more  above  the  condyle. 

Measuring  from  the  internal  condyle  to  the  styloid  process  of  the 
ulna,  the  forearm  is  shortened ;  the  same  result  will  be  obtained  also 
by  measuring  from  the  acromion  process  to  either  of  the  styloid  pro- 
cesses ;  while  from  the  acromion  process  to  the  condyle,  the  length 
will  be  the  same  in  both  arms. 

The  signs  which  have  now  been  enumerated  will  be  sufficient  to 
enable  us  to  make  the  diagnosis  promptly  in  the  great  majority  of 
cases,  but  if  considerable  swelling  has  already  taken  place,  the  diag- 
nosis may  be  rendered  exceedingly  difiicult,  if  not  impossible ;  and  in 
such  cases  we  should  confine  the  patient  at  once  to  his  bed,  and  pro- 
ceed to  reduce  the  tumefaction  by  cold  water  lotions  as  rapidly  as 
possible,  examining  the  limb  carefully  from  day  to  day  in  order  that 
we  may  seize  the  earliest  opportunity  to  ascertain  its  actual  condition 
and  apply  the  proper  remedy. 


I 


DISLOCATION    OF    RADIUS    AND    ULNA    BACKWARDS,      591 

In  relation  to  the  difficulty  of  diagnosis  in  certain  examples  of  this 
accident,  and  under  certain  circumstances,  Mr.  Skey,  in  his  Operative 
Surqery,  has  made  some  very  judicious  remarks. 

"Severe  injuries  of  the  elbow-joint,  whether  in  the  form  of  fracture, 
dislocation,  or  a  compound  of  the  two,  are  frequently  followed,  at  a 
short  interval,  by  swelling  of  a  formidable  kind,  in  which  it  is  impos- 
sible, but  by  the  aid  of  a  perfect  intimacy  with  the  anatomical  struc- 
ture of  the  joint,  to  detect  the  relations  of  one  part  with  another ;  but 
even  under  this  difficulty,  the  two  points  in  question  are  readily  dis- 
tinguishable. In  such  forms  of  swelling,  the  arm,  including  the  length 
of  six  inches  both  above  and  below  the  joint,  may  be  involved  in  the 
extravasation,  and  this  swelling  may  distend  the  arm  to  a  circumfer- 
ence of  one-third  beyond  its  natural  size.  In  such  circumstances,  in 
which  it  is  impossible  to  determine  with  any  certainty  whether  any, 
or  what  bones  are  broken,  or  whether  or  not  dislocated,  the  difficulty 
of  the  case  should  at  once  be  stated  to  the  friends  of  the  patient." 

Prognosis. — If  the  luxation  is  recent,  redaction  is  in  general  easily 
effected;  but  if  considerable  time  has  elapsed,  the  reduction  is  often 
accomplished  with  difficulty.  As  to  the  probability  of  its  reluxation, 
I  have  already  spoken  when  considering  the  subject  of  fractures  of  the 
coronoid  process.  Unless  this  process  is  broken,  it  is  not  likely  to 
occur  except  where  some  violence  has  again  been  applied.  It  has 
happened  to  me,  however,  to  find  these  bones  unreduced  in  several 
instances.  In  some  of  these  examples  surgeons  recognized  the  acci- 
dent and  supposed  that  the}'-  had  accomplished  reduction,  while  in 
others  the  dislocation  was  mistaken  for  a  fracture. 

A  lad,  W.  F.,  twelve  years  old,  residing  in  Erie  County,  N.  Y.,  was 
brought  to  me  six  weeks  after  the  accident  had  occurred.  The  surgeon 
who  was  first  called  declared  it  to  be  a  dislocation,  and  told  the  parents 
he  had  reduced  it ;  but  the  dislocation  was  now  complete,  and  the  arm 
immovably  fixed  in  its  abnormal  position. 

On  the  iOth  of  May,  1850,  J.  P.,  of  Canada  West,  £et.  25,  was  thrown 
from  a  load  of  hay,  striking  upon  his  left  hand,  and  producing  a  dis- 
location backwards  of  both  bones  at  the  elbow-joint.  A  Canadian 
surgeon,  who  saw  the  patient  within  three  hours,  recognized  the  dislo- 
cation, and  by  pulling  the  arm  straight  forwards  he  supposed  he  had 
reduced  it ;  the  patient  also  thought  he  felt  the  bones  slip  into  place. 
No  attempt  was  made  subsequently  to  flex  the  arm,  and  it  was  imme- 
diately dressed  with  a  straight  splint  laid  along  the  palmar  surface. 
On  the  sixth  day  it  was  found  to  be  unreduced,  and  the  surgeon  again 
attempted  to  reduce  it  as  before,  and  thought  he  had  succeeded.  The 
same  splint  was  reapplied.  At  about  the  end  of  six  weeks  three 
surgeons,  residing  in  Canada  also,  placed  the  patient  under  the  com- 
plete influence  of  chloroforn,  and  attempted  the  reduction.  They  first 
made  extension  for  half  an  hour  in  a  straight  line,  then  five  men 
seized  upon  the  arm  and  forearm,  bending  it  with  great  force  to  a  right 
angle.  It  was  now  believed  that  the  ulna  was  reduced,  but  not  the 
radius.  Four  days  after,  the  attempt  was  renewed.  Three  months 
after  the  accident  the  young  man  called  upon  me,  and  I  found  the  arm 
nearly  straight,  with  almost  complete  anchylosis  at  the  elbow-joint. 


592  DISLOCATIONS    OF    THE    EADIUS    AND    ULNA. 

Both  the  radius  and  ulna  were  displaced  backwards,  but  not  upwards. 
The  arm  was  of  the  same  length  with  the  other,  and  the  relation  of 
the  condyles  to  the  olecranon  was  so  manifest,  that  the  absence  of  the 
usual  displacement  upwards  was  easily  determined.  1  was  unwilling 
to  make  any  further  attempts  at  reduction,  not  believing  that  I  should 
succeed  after  so  much  time  had  elapsed,  and  after  so  many  ineffectual 
attempts  had  been  made  by  clever  surgeons. 

In  the  following  examples  the  dislocation  was  supposed  to  have 
been  a  fracture  of  the  lower  end  of  the  humerus. 

A  man,  residing  in  Pittsfield,  Mass.,  dislocated  his  left  arm  by  fall- 
ing from  a  horse.  The  surgeon  who  was  called  regarded  it  as  a  frac- 
ture at  the  base  of  the  condyles,  and  treated  it  accordingly.  Ten 
weeks  after,  the  error  was  discovered  and  an  attempt  was  made  to 
reduce  it,  but  without  success.  A  second  attempt  was  also  made,  with 
the  same  result. 

The  patient  was  brought  to  me  eight  months  after  the  accident,  with 
the  bones  still  unreduced.  The  forearm  hung  at  a  very  obtuse  angle 
with  the  arm,  and  there  was  very  slight  motion  at  the  elbow-joint.  I 
discouraged  any  further  attempts  at  reduction. 

Mr.  W.,  of  Alleghany  Co.,  N.  Y.,  ^t.  43,  fell  from  a  load  of  hay, 
striking  upon  his  left  arm,  Feb.  16,  1853.  Four  hours  after,  he  was 
seen  by  a  young  but  very  intelligent  surgeon,  who  thought  the  hume- 
rus was  broken  just  above  the  condyles.  After  eight  weeks,  the  fact 
that  it  was  a  dislocation  having  become  apparent,  three  surgeons,  well 
known  to  me  as  men  of  large  experience,  attempted  its  reduction, 
aided  by  pulleys  and  chloroform.  The  patient  was  also  bled,  and 
nauseated  with  antimony.  The  efforts  were  protracted  through  many 
hours,  and  frequently  varied.  A  second  attempt  made  by  these  same 
gentlemen,  a  few  days  after,  was  equally  unsuccessful. 

On  the  ninth  week  Mr.  W.  came  to  me,  and  I  placed  him  at  once 
in  the  Buffalo  Hospital  of  the  Sisters  of  Charity,  where,  assisted  by 
my  friend  Prof.  Moore,  of  Rochester,  I  renewed  the  attempt  at  re- 
duction. The  patient  was  placed  under  the  influence  of  chloroform, 
and  during  a  great  portion  of  the  time  occupied  the  pulleys  were 
in  use.  The  elbow  was  pulled  upon,  twisted,  flexed,  and  extended, 
until  there  seemed  to  be  neither  adhesions,  nor  ligaments,  nor  capsule 
to  prevent  the  reduction.  We  could  move  the  joint  in  every  direction, 
even  laterally,  as  well  as  forwards  and  backwards.  Still  the  bones 
would  not  return  to  their  sockets.  Section  of  the  triceps  seemed  to 
be  the  only  remaining  expedient,  but  the  injury  already  done  to  the 
joint  was  so  great  that  we  did  not  deem  it  prudent  to  prosecute  the 
attempt  any  further.  We  had  occupied  two  hours  in  the  various  pro- 
cedures. Violent  inflammation  supervened,  but  he  was  able  to  return 
home  in  about  two  weeks.  Two  years  after,  I  learned  that  the  arm 
still  remained  unreduced,  and  nearly  anchylosed  ;  the  whole  limb  was 
also  much  atrophied  and  very  weak. 

John  Sharkie,  set.  53,  fell  on  the  4th  of  Aug.  1854.  A  botanic  doctor, 
who  saw  him  on  the  same  day,  and  a  regular  physician,  who  saw  him 
on  the  third  day,  thought  he  had  broken  his  arm.  About  six  weeks 
after  this  he  came  under  the  charge  of  an  almshouse  doctor,  who 


DISLOCATION    OF    RADIUS    AND    ULNA    BACKWARDS.      593 


"rebroke"  it,  supposing  it  to  be  a  fracture;  and  two  months  later  he 
"  broke"  it  again ;  but  as  the  arm  was  not  improved  by  these  operations, 
he  finally  urged  the  poor  fellow  to  submit  to  amputation;  and  it  was 
in  reference  to  this  last  proposition  that  Sharkie  consulted  me,  I  found 
the  radius  and  ulna  dislocated  backwards  and  upwards  one  inch;  the 
arm  perfectly  straight  and  the  elbow  anchylosed  ;  no  pronation  or  supi- 
nation. I  did  not  think  it  prudent  to  make  any  attempt  to  reduce  it, 
but  assured  him  that  if  let  alone  it  would  ultimately  be  quite  useful 
in  many  ways,  and  that  he  should  never  think  of  having  it  cut  off". 

In  at  least  eight  additional  cases,  according  to  my  records,  the  acci- 
dent has  been  overlooked  by  reputable  surgeons;  the  injury  having 
been  supposed  to  be  either  a  fracture  or  a  mere  contusion.  Two  of 
these  had  been  examined  by  house  surgeons  at  Bellevue,  In  one 
other  case  my  house  surgeon  supposed  he  had  reduced  the  dislocation, 
when  he  had  not. 

In  three  or  four  instances,  also,  the  accident  has  been  overlooked 
by  the  patient  himself,  or  by  some  empiric,  no  surgeon  having  been 
called  to  see  the  case  until  after  the  lapse  of  several  days  or  weeks. 

In  general,  when  the  reduction  has  been  effected  promptly,  the 
patients  have  recovered  the  complete  use  of  the  elbow-joint  within  a 
few  weeks;  but  many  exceptions  have  from  time  to  time  come  under 
my  notice. 

A  lad  eight  years  old  was  brought  to  me,  whose  arm  had  been  dis- 
located six  months  before,  and  the  reduction  of  which  had  been  ac- 
complished easily  and  promptly  by 
Sir  Astley  Cooper's  method.  At 
this  time  the  arm  was  bent  to  a  right 
angle,  and  quite  stiff  at  the  elbow- 
joint.  Four  years  later  I  learned  that 
the  stiffness  still  continued  in  a  great 
measure,  with  only  slight  improve- 
ment. 

Treatment. — Sir  Astley  Cooper  thus 
describes  his  own  method  of  reducing 
this  dislocation :  "The  patient  is  made 
to  sit  upon  a  chair,  and  the  surgeon, 
placing  his  knee  on  the  inner  side  of 
the  elbow-joint,  in  the  bend  of  the 
arm,  takes  hold  of  the  patient's  wrist, 
and  bends  the  arm.  At  the  same 
time  he  presses  on  the  radius  and 
ulna  with  his  knee,  so  as  to  separate 
them  from  the  os  humeri,  and  thus 
the  coronoid  process  is  thrown  from 
the  posterior  fossa  of  the  humerus; 
and  whilst  this  pressure  is  supported 
by  the  knee,  the  arm  is  to  be  forcibly 

but  slowly  bent,  and  the  reduction  is  j^^,„^,.^^  ^.^,  ^,^  ,„,,  ,^  .,,  ,,„j ,,  ,^, 
soon  enected.  eibow. 


Fig.  256, 


594  DISLOCATIONS    OF    THE    EADIUS    AND    ULNA. 

The  same  practice  has  been  recommended  by  Erichsen,  Gibson, 
Samuel  Cooper,  and  others.  The  plan  recommended  by  Dorsey  is 
nearly  identical  with  that  just  described,  only  that,  instead  of  the  knee, 
he  advises  that  the  surgeon  "interlock  his  fingers  in  front  of  the  arm, 
just  above  the  elbow,  and  draw  it  backwards." 

On  the  other  hand,  Liston  and  Miller  recommend,  as  a  better  mode 
of  procedure,  that  the  patient  shall  be  seated  upon  a  chair,  and  that 
the  arm  and  forearm  shall  be  pulled  directly  backwards,  so  as  to  relax 
as  completely  as  possible  the  triceps  muscle,  while  counter-extension 
is  made  against  the  scapula. 

Skey  says :  "  Extension  of  the  forearm  should  be  made  from  the 
hand  or  wrist  in  a  straight  direction  downwards,  as  if  for  the  purpose 
of  simply  elongating  the  arm." 

Pirrie  prefers  that  an  assistant  shall  grasp  the  forearm  near  its  mid- 
dle, instead  of  the  wrist,  and  pull  the  arm  straight  forwards,  while  at 
the  same  moment  the  surgeon  seizes  upon  the  olecranon  process  with 
the  fingers  of  one  hand,  and,  placing  the  palm  of  the  other  against 
the  front  and  upper  part  of  the  forearm,  pulls  forcibly  backwards,  so 
as  to  draw  out  the  coronoid  process  from  the  olecranon  fossa.  Water- 
man recommends  forced  extension ;  that  is,  bending  the  forearm 
forcibly  back,  as  preliminary  to  flexion,  with  the  view  of  lifting  the 
coronoid  process  from  the  olecranon  fossa.^ 

For  myself,  having  generally  practised  the  method  recommended 
by  Sir  Astley,  and  having  usually  succeeded  in  the  first  attempt  and 
with  the  employment  of  only  moderate  force,  I  confess  that  my  pre- 
dilections are  in  its  favor;  yet  I  am  not  entirely  certain  but  that  an 
equal  experience  wilih  either  of  the  other  modes  recommended  might 
have  changed  these  convictions.  The  truth  is,  I  think,  that  in  recent 
cases  very  little  force  is  generally  requisite  to  accomplish  the  reduc- 
tion, and  that  it  is  not  very  material  which  of  these  several  modes  we 
adopt;  but  in  case  of  a  failure  by  one  mode,  we  ought  immediately 
and  without  hesitation  to  resort  to  another,  as  the  following  case  of 
failure  by  flexion  will  illustrate : — 

A 'lad,  £et.  11,  fell  in  a  gymnasium  from  a  height  of  six  feet,  striking 
probably  upon  his  hand.  I  saw  him  within  twenty  minutes,  and 
found  the  arm  in  the  usual  position.  I  attempted  immediately  to  re- 
duce it  by  Sir  Astley's  method,  but  after  a  fair  yet  unsuccessful  trial, 
I  extended  the  forearm  upon  the  arm  until  it  was  nearly  straight, 
and  then,  with  only  moderate  force,  drew  it  promptly  into  place. 

If  we  still  continue  to  encounter  difficulties,  the  patient  ought  at 
once  to  be  placed  under  the  influence  of  an  anaesthetic,  and,  if  neces- 
sary, the  pulleys  should  be  employed. 

When  the  reduction  is  accomplished,  which  is  indicated  generally 
by  the  sudden  slipping  of  the  bones  and  by  the  restoration  of  the 
natural  form  to  the  elbow-joint,  the  surgeon,  in  order  to  confirm  his 
opinion,  must  flex  the  forearm  upon  the  arm  to  a  right  angle.  If  the 
bones  are  in  place,  and  there  is  not  much  swelling,  this  can  generally 

'  New  Method  of  Reduction  of  the  Elbow,  b}^  Thomas  "Waterman,  M.D.,  Boston 
Med.  and  Surg.  Journ.,  vol.  iv.,  Nos.  13-13,  new  series,  1869. 


DISLOCATIOX    OF    EADIUS    AXD    ULNA    BACKWARDS.      595 

be  done  without  causing  much,  if  any,  pain ;  but  if  it  cannot  be  done, 
this  fact  furnishes  presumptive  evidence  that  the  reduction  is  not 
effected.  In  one  instance,  however,  of  recent  luxation,  this  rule  has 
not  held  good.  A  girl,  aet.  10,  fell  from  a  tree  upon  her  hand.  I  was 
in  attendance  within  half  an  hour,  and  found  the  usual  signs  charac- 
terizing this  accident.  Reduction  was  accomplished  readily  by  pulling 
at  the  hand  moderately,  with  the  forearm  flexed,  while  my  left  hand 
pressed  back  the  lower  part  of  the  humerus.  After  the  reduction  it 
was  found  impossible  to  flex  the  arm  to  a  right  angle  without  causing 
severe  pain,  and  it  became  necessary,  after  placing  it  in  a  sling,  to 
allow  the  hand  to  drop  very  low  beside  the  body.  A  good  deal  of 
inflammation  followed  ;  but  in  a  few  weeks  the  arm  was  well,  only  that 
for  a  period  of  two  years  or  more  the  elbow  remained  very  tender. 

On  the  other  hand,  an  omission  to  apply  this  rule  has  often  led  the 
surgeon  to  believe  the  reduction  accomplished  Avhen  it  was  not.  This 
same  thing  has  happened  to  myself,  and  as  it  is  the  only  instance  in 
which  I  have  omitted  to  adopt  this  test,  and  the  only  one  also  in  which 
I  have  left  a  bone  unreduced  which  I  believed  to  have  been  reduced, 
it  will  be  proper  to  state  the  case  and  its  results  more  fully. 

A  lad,  aet.  11,  fell  from  a  fence  on  the  22d  of  December,  1858,  and 
dislocated  both  bones  backwards.  I  saw  him  within  two  hours  from 
the  occurrence  of  the  accident.  The  elbow  was  already  considerably 
swollen  and  quite  tender,  but  the  signs  of  dislocation  were  very  mani- 
fest. Seizing  the  wrist  with  one  hand,  and  placing  my  knee  against 
the  front  and  lower  part  of  the  humerus,  I  pulled  steadily  for  some 
time,  and  with  much  more  force  than  is  usually  necessary,  until  at 
length  two  distinct  and  successive  snaps  were  felt,  such  as  one  often 
feels  when  the  two  bones  resume  their  sockets.  Relinquishing  my 
grasp,  it  was  observed  by  myself  and  the  parents  that  the  deformity 
had  disappeared.  The  I'eduction  seemed  to  be  complete,  and  so  I 
announced.  I  then  requested  the  lad  to  permit  me  to  bend  the  elbow, 
and  place  it  in  a  sling,  but  this  he  peremptorily  refused  to  do,  and  ran 
away  from  me,  nor  would  any  arguments  or  entreaties  persuade  him 
to  allow  me  again  to  touch  it.  I  reassured  the  parents  and  child,  how- 
ever, that  all  was  rio;ht,  and  left  the  house.  During  several  successive 
da3^s  I  saw  the  little  patient,  but  although  the  arm  remained  swollen 
and  very  tender,  I  did  not  suspect  the  cause  until  the  ninth  day ;  and 
on  the  tenth  day,  having  placed  him  under  the  influence  of  chloroform, 
the  reduction  was  easily  and  satisfactorily  accomplished.  The  recovery 
has  been  slow.  At  the  end  of  six  weeks  I  found  the  motions  of  the 
elbow-joint  not  completely  restored,  and  the  forefinger  was  partially 
paralyzed;  but  from  this  condition  it  has  gradually  recovered,  and 
two  months  later  the  functions  of  the  arm  and  hand  were  completely 
restored. 

The  mistake  in  this  instance  was  the  more  mortifying  because  I  had 
just  seen  a  case  in  a  lad  only  a  little  older,  in  which  another  surgeon 
had  committed  the  same  error,  and  after  the  lapse  of  twelve  or  four- 
teen days  I  had  myself  made  the  reduction ;  and  I  was  fully  awake, 
therefore,  to  the  possibility  of  the  mistake. 


596  DISLOCATIONS    OF    THE    EADIUS    AND    ULNA. 

The  circumstance  of  the  diminution,  and  apparent  disappearance  of 
the  deformity,  and  the  sensation  of  a  double  click,  can  only  be  explained 
by  assuming  that  originally  the  coronoid  process  was  resting  in  the 
olecranon  fossa,  and  that  by  manipulation  the  bones  had  been  removed 
nearer  their  sockets,  yet  not  actually  reduced.  The  swelling,  also, 
rendered  more  difficult  a  diagnosis  which,  now,  nothing  but  the  flexion 
of  the  forearm  could  have  determined  positively. 

If  much  time  has  elapsed  since  the  occurrence  of  the  dislocation  the 
reduction  is  accomplished  with  difficulty,  if,  indeed,  it  can  be  reduced 
at  all.  There  are  many  cases  upon  record,  however,  in  which  surgeons 
have  been  successful  after  the  lapse  of  many  weeks,  or  even  months. 
Boyer  thought  it  was  not  possible  to  effect  the  reduction  after  four  or 
six  weeks;  but  Capelletti,  of  Trieste,  succeeded  after  seventy  days;^ 
Sir  Astley  Cooper,  at  three  months  f  Malgaigne,  after  three  months 
and  twenty-one  days.^  Eoux  succeeded  in  a  case  of  a  young  man 
twenty-two  years  of  age,  whose  elbow  had  been  dislocated  five  months.* 
Blackman,  of  Cincinnati,  informs  me  that  he  has  reduced  a  lateral  luxa- 
tion after  five  months.  Brainard,  of  Chicago,  reduced  a  dislocated 
elbow  in  a  boy  of  nineteen  years,  after  five  months  and  thirteen  days. 
In  this  case  the  surgeon  who  had  first  seen  the  patient  supposed  that 
he  had  reduced  the  dislocation.'  Gorre,  Gerdy,  and  Drake  succeeded 
in  four  cases  after  six  months;"  and  finally,  Starch  claims  to  have 
been  successful  after  two  years  and  one  month.'^  To  which  enumera- 
tion Denucd  has  added  seventeen  other  examples,  said  to  have  been 
reduced  at  various  periods,  ranging  from  one  month  to  one  hundred 
and  fourteen  days.^ 

1  have  reduced  quite  a  number  of  these  old  luxations,  the  five  last 
of  which  will  be  briefly  recorded. 

Thomas  Robertson,  net.  35,  was  admitted  to  Bellevue  Hospital,  Dec. 
14:th,  1864,  with  a  simple  dislocation  of  the  radius  and  ulna  backwards, 
which  had  existed  thirty-one  days,  but  which  had  not  been  up  to  this 
moment  recognized  by  his  surgeon.  I  reduced  it  before  the  class,  by 
Sir  Astley's  method,  the  patient  being  under  the  influence  of  ether. 
Considerable  force  was  required. 

J.  G.,  set.  7,  was  brought  to  me  in  Nov.  1865,  with  a  backward  dis- 
location of  the  right  radius  and  ulna  which  had  existed  nine  weeks. 
The  arm  was  nearly  straight  and  fixed.  Having  placed  him  under 
the  influence  of  ether,  assisted  by  Dr.  Gurdon  Buck,  of  this  city,  I 
proceeded  to  flex  the  arm  slowly,  and  after  a  few  seconds,  and  when 
the  elbow  was  bent  about  ten  or  fifteen  degrees,  the  olecranon  process 
separated  at  the  line  of  epiphyseal  union.  In  a  few  moments  the 
reduction  was  completed,  and  the  arm  brought  to  an  acute  angle,  but 
the  olecranon  had  separated  full  half  an  inch.     We  were  quite  certain 

'  Capelletti,  Am.  Journ.  Med.,  vol.  xix.,  from  Aiinal.  Univ.  de  Med.  for  Oct.  1835. 

2  Sir  Astley  Cooper,  On  Dislocations  and  Fractures,  Amer.  ed.,  p.  388. 

»  Malgaigne,  Amer.  Journ.  Med.  Sci.,  vol.  xxiii.  p.  238,  from  Revue  Med.,  Dec. 
1837. 
<  Roux,  Amer.  Journ.  Med.  Sci.,  vol.  xvi.  p.  520,  from  Archives  Gen.,  Dec.  1834. 

5  Brainard,  Illinois  and  Indiana  Med.  Journ.,  1847. 

6  ]\Iemoire  sur  les  luxations  da  coude,  par  Paul  Denuce,  Paris,  1854.  pp.  86,  87. 

7  Denuce,  op.  cit.,  p.  87.  s  Qp,  cit. 


DISLOCATION    OF    EADIUS    AND    FLNA    BACKWAEDS.      597 

that  the  ulna  was  perfectly  reduced,  but  the  head  of  the  radius  did  not 
seem  to  occupy  its  original  position  fully.  Only  moderate  inflam- 
mation ensued.  Passive  motion  was  soon  commenced  and  consider- 
able motion  of  the  joint  was  finally  obtained. 

In  April,  1869,  a  gentleman,  set.  30,  consulted  me  on  account  of  a 
dislocation  which  had  then  existed  ten  weeks,  and  which  had  not  been 
recognized  by  his  surgeon.  In  attempting  to  reduce  the  dislocation 
I  fractured  the  olecranon,  and  brought  the  ulna  into  position  ;  but  I 
could  not  reduce  the  radius.  Almost  complete  anchylosis  of  the  elbow 
remains. 

In  1870,  a  man  was  brought  to  me  whose  elbow  had  been  dislocated 
eight  weeks.  Under  ether,  I  succeeded  in  reducing  the  dislocation, 
but  fractured  the  olecranon  process  in  doing  so.  He  has  recovered 
very  good  use  of  the  joint. 

October  22,  1869,  before  the  class  of  medical  students  at  Bellevue, 
I  reduced  a  dislocation  in  the  case  of  a  woman  set.  37,  which  had  ex- 
isted since  the  10th  of  the  preceding  March,  a  little  more  than  seven 
months.  I  have  seen  her  often  since;  she  has  a  somewhat  limited 
but  very  useful  motion  of  the  joint. 

Dr.  W.  F.  Westmoreland,  of  Atlanta,  Ga.,  has  reported  a  case  in 
which  he  succeeded  readily  in  reducing  a  dislocation  of  the  elbow 
backwards  of  five  months'  standing  in  a  woman  aged  22  years.  The 
reduction  was  followed  by  great  pain,  a  good  deal  of  swelling,  tempo- 
rary improvement  of  circulation  in  the  radial  artery,  complete  para- 
lysis of  the  little  finger,  and  partial  paralysis  of  the  middle  and  ring 
fingers.  On  the  fourteenth  day,  at  which  period  the  history  of  the 
case  closes,  all  these  symptoms  were  rapidly  disappearing.^ 

Nevertheless,  the  fact  is  in  the  main  as  stated  by  Boyer ;  and  if  so 
many  cases  can  be  found  in  which  surgeons  have  succeeded  at  a  late 
period,  they  are  not  probably  in  the  proportion  of  one  to  five  as  com- 
pared with  the  failures :  but  the  failures  have  not  received  the  same 
publicity.  Nor,  indeed,  have  all  the  severe  accidents,  such  as  violent 
inflammation,  suppuration,  gangrene,  and  even  death,  been  faithfully 
declared.  Denuce  says  he  has  been  able  to  trace  out  five  or  six  ex- 
amples in  which,  although  the  arm  was  reduced,  grave  accidents 
resulted,  and  Velpeau's  patient  actually'  died  in  consequence. 

Dixi  Crosby,  of  New  Hampshire,  has  treated  two  cases  of  ancient 
dislocation  of  the  forearm  backwards,  by  bending  the  elbow  forcibly 
so  as  to  break  the  olecranon  process,  after  which  the  reduction  was 
easily  accomplished  by  extension.  R.  D.  Mussey,  of  Cincinnati,  has 
succeeded  once  in  the  same  manner.^  I  have  reported  three  similar 
examples. 

The  dislocation  being  reduced,  it  may  be  a  matter  of  prudence,  some- 
times, to  apply  a  right-angled  splint,  first  carefully  padded,  to  the 
palmar  surface  of  the  arm  and  forearm  ;  remembering,  however,  that 
considerable  swelling  will  soon  occur,  and  that  it  ought  not  therefore 
to  be  bandaged  to  the  limb  very  tightly.  At  least  once  a  day  it  should 
be  removed,  and  the  arm  examined ;  and  in  very  few  cases  can  it  be 

'  Westmoreland,  Atlanta  Med.  and  Surg.  Journ.,  May,  1866. 
2  Crosby,  Mussey,  Trans.  Amer.  Med.  Assoc,  vol.  iii.  p.  357. 


598 


DISLOCATIOXS    OF    THE    RADIUS    AND    ULNA. 


necessary  or  judicious  to  continue  its  application  beyond  one  week. 
At  the  same  time,  if  there  is  any  especial  tendency  in  the  radius  to 
become  displaced  backwards,  owing  to  a  rupture  of  its  annular  liga- 
ment, this  must  be  prevented,  if  possible,  by  a  compress  and  bandage. 
Some  surgeons  regard  these  precautions  as  necessary  in  all  cases,  but 
I  have  seldom  employed  any  splint  or  bandage  whatever,  nor  have  I 
ever  had  reason  to  regret  this  omission. 

Finally,  we  are  to  place  the  arm  in  a  sling,  and  adopt  such  measures 
as  are  calculated  at  first  to  reduce  the  inflammation  ;  and  at  a  very 
early  day  we  ought  to  begin  to  move  the  elbow-joint,  in  order  to 
prevent  anchylosis. 


Ficr.  357. 


§  2.  Dislocations  or  the  Radius  and  Ulna  Outwards  (to  the  Radial 

Side.) 

The  large  majority  of  outward  dislocations  of  the  forearm  are  in- 
complete ;  indeed,  only  nine  examples  of  a  complete  dislocation  have 
been  collected  by  Denuce,  including  two  seen  by  himself.  Malgaigne 
has  since  added  two  more,  making  in  all  eleven  cases.  All  these 
examples  have  occurred  in  the  practice  of  French  surgeons.  So  far 
as  I  am  able  to  discover,  no  American  or  English  surgeon  has  ever 
reported  a  single  example. 

Incomplete  dislocations  must,  therefore,  in  this  case  be  regarded  as 
typical ;  but  even  these  are  by  no  means  frequent. 

Causes. — A  careful  examination  of  a  large  number  of  recorded  ex- 
amples, and  of  those  which  have  come  under  my  own  eye,  renders  it 
certain  that  a  majority  of  these  accidents  result 
from  a  blow  received  directly  upon  the  inner  side 
of  the  forearm  or  upon  the  outer  side  of  the  humerus, 
or  from  the  action  of  two  forces  pressing  in  an 
opposite  direction.  Of  course  those  forces  must 
act  upon  the  bones  somewhere  in  the  neighborhood 
of  the  elbow-joint.  Occasionally  it  has  been  pro- 
duced by  a  fall  upon  the  hand ;  sometimes  by  a 
violent  twist  of  the  arm,  as  when  the  hand  is  caught 
in  machinery  ;  and  in  other  cases  it  has  been  found 
consecutive  upon  a  dislocation  backwards,  being 
produced  in  the  attempts  made  to  accomplish  re- 
duction of  this  latter  form  of  dislocation. 

Pathology. — In  most  of  the  examples  of  simple 
incomplete  outward  luxation  of  the  forearm,  the 
great  sigmoid  cavity  of  the  ulna  still  embraces  the 
lower  end  of  the  humerus,  but  instead  of  reposing 
upon  the  trochlea,  it  is  carried  outwards  half  an 
inch  or  more,  so  as  to  rest  its  central  crest  upon 
the  depression  which  separates  the  condyle  from 
the  trochlea.  If  the  annular  ligament  remains 
unbroken,  the  radius  is  displaced  in  the  same  di- 
Most  frequent  form  of    ^qq^\q^  and  to  the  samc  cxtcut,  Its  hcad  resting 

incomplete  outward  dislo-  .  jj-  iii  ti 

cation  of  the  forearm.         agamst  and  Qirectly  below  the  epicondyle. 


DISLOCATION"    OF    RADIUS    AND    ULXA    OUTWAEDS.      599 

Occasionally,  however,  where  the  violence  has  been  greater,  the  cen- 
tral crest  of  the  great  sigmoid  cavity  rests  fairly  upon  the  condyle,  or 
upon  the  articulating  surface  of  the  humerus  where  the  head  of  the 
radius  was  formerly  applied,  and  the  dislocation  approaches  more  nearly 
to  the  character  of  a  complete  luxation.  At  the  same  time,  owing 
perhaps  to  the  resistance  afforded  by  the  skin,  or  some  of  the  liga- 
ments, the  head  of  the  radius  may  be  thrown  either  forwards  or  back- 
wards, so  as  to  be  out  of  line  with  the  ulna.  Such  a  displacement 
generally  implies  a  rupture  of  the  annular  ligament. 

We  have  now  only  to  suppose  the  action  of  a  more  considerable 
force  in  the  same  direction  to  render  the  dislocation  com.plete ;  in 
which  case  the  upper  end  of  the  radius  is  sometimes  thrown  com- 
pletely forwards,  and  its  head  may  even  be  found  resting  in  front  of 
the  ulna,  occasioning  an  extreme  pronation  of  the  forearm  and  hand. 
The  anconeus  and  brachialis  anticus  are  the  only  muscles  in  either 
of  these  dislocations  whose  fibres  are  generally  much  disturbed;  the 
biceps  and  triceps  being  only  made  to  traverse  the  articulation  a  little 
more  obliquely. 

Denuc^,  Malgaigne,  A.  Cooper,  and  others  have  preferred  to  speak 
of  the  dislocation  backwards  and  outwards  as  a  distinct  form  or  species 
of  dislocation.  I  prefer  to  regard  it  as  only  a  variety  of  the  outward 
luxation,  since  it  may,  and  no  doubt  often  does,  occur  consecutively 
upon  a  simple  incomplete  outward  dislocation;  and  if  the  dislocation 
outward  is  complete,  the  bones  of  the  forearm  can  sfth-cely  fail  to  be 
drawn  more  or  less  upwards.  Sometimes  also  it  has  been  consecutive 
upon  a  simple  backward  dislocation,  or  upon  unsuccessful  attempts  at 
reduction  where  the  form  of  dislocation  was  originally  backwards ; 
yet,  as  it  does  not  so  naturally  follow  upon  a  complete  backward  dis- 
location as  upon  a  complete  outward  luxation,  I  find  sufficient  reason 
for  studying  its  mechanism  in  this  place. 

The  beak  of  the  olecranon  process  not  only,  but  a  large  portion  of 
the  body  of  this  process,  now  lies  above  and  behind  the  condyle;  the 
brachialis  anticus  becomes  more  stretched,  if  not  actually  torn;  and  the 
biceps  is  laid  against  the  articulating  surface  of  the  humerus ;  but  the 
triceps  becomes  again  relaxed,  as  in  simple  dislocation  backwards  and 
upwards. 

In  all  these  dislocations  the  capsular  ligaments  are  more  or  less  ex- 
tensively torn,  but  the  principal  arteries  and  nerves  do  not  generally 
suffer  greatly,  if  at  all. 

ISymptoms. — The  forearm  is  usually  flexed  to  about  the  same  angle 
at  wbich  we  have  found  it  in  dislocations  backwards ;  once  I  have 
found  it  nearly  or  quite  straight;  occasionally  it  is  flexed  to  a  right 
angle.  In  all  the  cases  seen  by  me  the  forearm  has  been  pronated, 
and  the  elbow-joint  has  been  very  immovable.  The  most  striking 
diagnostic  sign,  however,  consists  in  the  unnatural  form  of  the  elbow- 
joint,  which  is  so  remarkable  as  not  to  be  easily  misunderstood.  The 
internal  condyle  of  the  humerus  (epitrochlea)  projects  strongly  to  the 
inner  side,  leaving  a  deep  depression  below;  while  upon  the  other 
side,  the  head  of  the  radius,  with  its  cup-like  extremity,  can  be  dis- 
tinctly felt,  and  made  to  rotate  outside  of  its  socket.     The  olecranon 


600  DISLOCATIONS    OF    THE    KADIUS    AND    ULNA. 

process,  driven  from  its  fossa,  projects  more  or  less  posteriorly,  and 
even  the  fossa  itself  may  sometimes  be  plainly  felt. 

A  girl,  twelve  years  old,  bad  fallen  upon  the  inside  of  her  elbow, 
producing  a  dislocation  outwards  of  the  forearm.  I  saw  her  within 
half  an  hour.  The  forearm  was  bent  upon  the  arm  about  fifteen  de- 
grees, and  immovably  fixed.  The  head  of  the  radius  could  be  dis- 
tinctly felt  external  to  and  a  little  in  front  of  the  outer  condyle,  while 
the  olecranon  process  of  the  ulna,  which  rested  upon  the  back  and 
outer  surface  of  the  humerus,  was  less  distinctly  felt  than  in  the  oppo- 
site arm.  The  inner  condyle  projected  sharply  to  the  inside,  and  the 
olecranon  fossa  was  plainly  felt  with  the  fingers.  The  child  was  suf- 
fering very  little  pain. 

Seizing  the  wrist  with  my  right  hand  and  the  lower  end  of  the 
humerus  with  the  left,  and  making  moderate  extension  in  these  oppo- 
site directions,  the  bones  easily,  and  after  only  a  moment's  efibrt,  re- 
sumed their  places.     Her  recovery  was  rapid  and  complete. 

James  O'Neil,  set.  16,  was  admitted  to  Bellevue  Hospital  in  Dec. 
1865,  with  a  dislocation  caused  by  the  kick  of  a  horse,  the  blow 
having  been  received  on  the  ulnar  side  of  the  forearm  near  the  elbow- 
joint.  When  he  came  under  my  notice  the  dislocation  had  existed 
three  weeks.  I  found  the  head  of  the  radius  reposing  upon  the  radial 
and  posterior  side  of  the  humerus.  The  ulna  was  displaced  one  inch 
to  the  radial  side.  The  forearm  was  not  at  all,  or  but  very  slightly,- 
flexed  upon  tl^arm.  The  natural  deflection  of  the  forearm  to  the 
radial  side  was  a  little  exaggerated:  forearm  pronated:  elbow-joint 
admitting  of  a  little  motion;  but  motion  caused  great  pain. 

This  patient  was  not  in  my  service,  and  I  have  not  learned  the 
result  of  the  attempt  at  reduction. 

If  the  dislocation  is  complete,  the  position  of  the  arm  is  usually  the 
same,  but  the  pronation  of  the  hand  is  greater,  and  the  projection  of 
the  inner  condyle  more  striking. 

If  now  the  bones,  by  a  continuance  of  the  original  force,  or  by  the 
action  of  the  triceps,  are  drawn  upwards  also,  the  arm  becomes  a  little 
more  flexed,  and  the  olecranon  process  more  prominent,  while  the 
length  of  the  whole  limb  is  sensibly  diminished. 

Prognosis. — In  recent  cases  of  incomplete  outward  luxation,  and 
where  no  complications  exist,  the  reduction  is  generally  easily  effected ; 
and  M.  Thierry  claims  to  have  reduced  an  outward  and  backward 
luxation  after  eight  months.  A  patient  of  whom  Debruyn  has  spoken 
was  not  so  fortunate.  On  the  16th  of  April,  1841,  a  lad,  set.  18,  fell 
upon  the  palm  of  his  hand  and  dislocated  both  bones  outwards  and 
backwards;  on  the  following  morning  a  surgeon  attempted  to  reduce 
the  dislocation,  and  the  attempt  was  repeated  on  the  next  day  by  an- 
other surgeon ;  but  on  the  day  following  this  last  attempt,  gangrene 
ensued  in  consequence  of  the  great  violence  employed  by  the  surgeons, 
and,  although  the  limb  was  amputated,  the  patient  died.  The  autopsy- 
showed  that  both  the  brachial  artery  and  the  median  nerve  were  torn 
asunder,  and  that  the  tendons  of  the  biceps  and  the  brachialis  anticus 
were  slipped  behind  the  outer  condyle,  probably  having  been  thrown 


DISLOCATION    OF    RADIUS    AND    ULNA    OUTWARDS.      601 

into  this  position  during  the  violent  twistings  to  which  the  arm  had 
been  subjected.' 

I  have  seen  three  exanaples  of  dislocations  upwards  and  outwards 
which  the  medical  attendants  had  failed  to  reduce.  The  first  was  in 
the  case  of  a  lad,  Wm.  Kinkaid,  fourteen  years  old,  who  had  fallen 
from  a  wagon  and  struck  upon  the  palm  of  his  left  hand.  The  sur- 
geon who  was  immediately  called  made  extension,  and  supposed  that 
the  reduction  was  accomplished.  The  lad  was  brought  to  me  a  few 
months  after  the  accident.  The  arm  was  slightly  flexed,  and  neither 
prone  nor  supine.  There  existed  only  a  slight  motion  at  the  elbow- 
joint.  I  did  not  think  it  worth  while  to  make  any  attempt  at  reduc- 
tion. Several  years  after  this,  in  the  month  of  February,  1859, 1  had 
an  opportunity  of  examining  the  arm  again.  He  had  now  recovered 
considerable  motion  in  the  joint,  but  he  could  not  tie  his  cravat. 
Pronation  and  supination  were  perfect. 

In  the  second  example,  a  lady,  set.  33,  had  fallen  upon  the  inside  of 
her  elbow,  and  reduction  not  having  been  accomplished,  I  found  her, 
nine  weeks  after  the  accident,  with  scarcely  any  motion  at  the  elbow- 
joint,  and  complaining  of  a  numbness  in  the  forearm  and  hand. 

The  third  instance  of  unreduced  dislocation  I  will  relate  more  at 
length. 

Francis  Banfield,  aged  twenty- two  years,  a  resident  of  Alleghany 
County,  N.  Y.,  on  the  31st  of  September,  1857,  fell  from  the  sweep  of  a 
threshing-machine  to  the  ground,  a  distance  of  about  m^  feet,  striking 
upon  the  palm  of  his  hand,  his  arm  being  extended  in  front  of  him.  On 
rising,  he  found  his  arm  forcibly  flexed  and  abducted.  He  straight- 
ened it  without  difficulty,  and  it  assumed  the  position  it  now  occupies. 
A  physician  was  called  and  saw  the  patient  an  hour  and  a  half  after 
the  accident,  who  pronounced  it  a  case  of  dislocation  of  the  radius  and 
ulna,  and  made  efforts  at  reduction,  which  he  continued  from  8|  A.  M. 
until  2  P.M.,  a  period  of  five  and  a  half  hours,  to  no  purpose,  when 
he  abandoned  the  attempt.  During  the  attempt  at  reduction,  the  ex- 
tension was  made  at  times  with  the  arm  flexed,  and  at  others  extended. 
At  9  P.  M.  another  physician  was  called,  who  made  efforts  at  reduc- 
tion until  3  A.  M.,  upwards  of  six  hours,  at  which  time  he  also  aban- 
doned the  attempt.  On  the  third  day  another  physician,  the  patient 
being  under  the  influence  of  ether,  made  efforts  at  reduction  for  twenty 
minutes,  when  he  pronounced  it  in  place,  and  applied  a  bandage. 
From  the  patient's  account,  the  arm  was  swollen  to  such  an  extent  as 
to  render  this  point  difficult  to  determine.  On  the  fifth  day  the  first 
physician  was  called,  and  believing  that  he  discovered  a  grating, 
pronounced  it  a  fracture  of  the  external  condyle. 

Four  months  after  the  accident,  when  the  patient  applied  to  me,  the 
limb  presented  the  following  appearances:  "The  forearm  extended 
upon  the  arm ;  looking  at  the  limb  along  its  radial  margin,  we  notice 
a  gentle  outward  inclination  of  the  forearm  from  the  elbow  down,  but 
by  manipulation  this  may  be  greatly  increased ;  the  power  of  prona- 
tion and  supination  is  not  affected;   the  inner  condyle  projects  an 

'  Denuce,  op.  cit.,  p.  103. 

89 


602  DISLOCATIONS    OF    THE    KADIUS    AND    ULNA. 

incli  to  the  ulnar  sifle;  the  head  of  the  radius,  completely  removed 
from  its  socket,  projects  to  an  equal  extent  on  the  radial  side.  _  The 
top  of  the  olecranon  process  is  an  inch  higher  than  the  top  of  the  inner 
condyle,  so  that  the  radius  and  ulna  are  carried  upwards  as  well  as 
outwards." 

I  believe  that  the  external  condyle  was  not  broken,  as  in  that  case 
the  arm  would  be  permanenthj  deflected  outwards  to  a  much  greater 
extent.  For,  although  this  arm  may  be  deflected  outwards  by  the 
surgeon  to  an  angle  of  135°,  still  the  degree  of  mobility  which  exists 
would  be  adverse  to  the  supposition  of  its  being  a  fracture  of  the 
external  condyle.  The  condyles  also  can  be  plainly  felt  in  their 
natural  situations,  which  would  not  be  the  case  if  a  fracture  of  the 
external  condyle  existed.  The  patient  was  advised  not  to  submit  to 
any  further  attempts  at  reduction. 

The  following  will  serve  as  an  illustration  of  a  recent  accident  of 
this  character : — 

John  Collins,  of  Buffalo,  let.  8,  fell  while  wrestling,  his  companion 
falling  upon  his  arm.  I  found  the  forearm  slightly  flexed,  pronated, 
and  both  radius  and  ulna  thrown  over  to  the  radial  side  and  carried 
upwards.  Pressing  firmly  upon  the  radius  from  the  outside,  the  bones 
assumed  suddenly  the  position  of  a  backward  and  upward  dislocation, 
from  which  position  they  were  readily  reduced  to  their  original  sockets 
by  simple  extension. 

Treatment.— ^9i  relation  to  the  treatment  of  these  accidents  we  have 
little  to  add  to  what  has  already  been  said  of  the  treatment  of  dislo- 
cations backwards.  The  reduction,  if  effected  at  all,  has  generally 
been  accomplished  by  moderate  extension,  or  by  extension  combined 
with  lateral  pressure.  If  the  head  of  the  radius  is  in  front  of  the 
humerus,  or  of  the  ulna,  the  hand  should  be  first  supined,  and  then 
the  extension  should  be  applied.  In  some  cases  the  reduction  has 
been  effected  by  placing  the  knee  in  the  bend  of  the  elbow  and  flexing 
the  forearm,  while  the  surgeon  was  making  extension  from  the  hand. 

§  3.  Dislocation  of  the  Radius  and  Ulna  Inwards  (to  the  Ulnar  Side). 

This  form  of  dislocation  is  much  more  rare  than  the  dislocation 
outwards,  a  fact  which  may  perhaps  find  a  sufficient  explanation  in 
the  peculiar  form  of  the  trochlea,  the  inner  half  of  which  rises  much 
higher  than  the  outer,  forming  thus  an  elevated  inclined  plane,  over 
which  the  articulating  surface  of  the  ulna  must  rise  before  the  dislo- 
cation can  occur. 

Like  the  opposite  dislocation,  the  typical  form  of  the  accident  is 
that  in  which  the  displacement  is  incomplete;  indeed,  no  example  of 
a  complete  inward  dislocation  has,  we  think,  iDcen  yet  recorded. 

Causes. — A  fall  upon  the  hand  or  forearm,  a  blow  upon  the  radial 
side  of  the  forearm  near  its  upper  end,  or  upon  the  ulnar  side  of  the 
arm  near  its  lower  end,  a  violent  wrenching  of  the  limb  are  among 
the  causes  which  may  occasion  this  dislocation. 

Pathology. — The  ridge  which  divides  antero-posteriorly  the  greater 
sigmoid  cavity  of  the  ulna,  having  been  driven  over  the  elevated 


DISLOCATION    OF    RADIUS    AND    ULNA    INWARDS.       603 


Fio;.  2.58. 


inner  margin  of  the  trochlea,  falls  down  upon  the  epitrochlea,  so  as, 
in  some  sense,  to  embrace  it  instead  of  the  trochlea ;  while  the  head 
of  the  radius  passes  inwards  also,  and  is  made  to  occupy  the  trochlea, 
from  which  the  ulna  has  escaped.  Generally  the  head  of  the  radius 
is  found  in  the  same  line  with  the  ulna  (Fig.  258), 
but  it  may  suffer  a  luxation  and  be  found  a  little 
in  advance  of  the  ulna,  or  possibly  a  little  in  the 
rear. 

I  choose  also  to  regard  the  dislocation  inwards 
and  upwards  as  only  a  variety  of  the  dislocation 
inwards;  in  which  form  of  the  accident  the  coronoid 
process  of  the  ulna  is  thrust  upwards  above  the 
epicondyle,  and  the  head  of  the  radius  occupies  the 
olecranon  fossa,  or  rests  upon  the  back  of  the 
humerus  somewhere  in  this  vicinity. 

In  addition  to  the  injury  suffered  by  the  liga- 
ments and  muscles,  the  ulnar  nerve  in  both  varieties 
of  inward  dislocation  is  peculiarly  liable  to  contu- 
sion, in  consequence  of  its  being  crushed  between 
the  olecranon  process  and  the  epitrochlea. 

Symptoms. — If  the  dislocation  is  only  inwards, 
the  olecranon  process  can  be  felt  projecting  upon 
the  inner  side,  and  completely  concealing  the  epi- 
condyle ;  while  the  head  of  the  radius,  having  aban- 
doned its  socket,  may  be  felt  indistinctly  in  the 
bend  of  the  arm.  The  external  condyle  (epicon- 
dyle) is  remarkably  prominent.  The  forearm  is 
generally  more  or  less  flexed,  and  the  hand  forci- 
bly pronated.  The  natural  outward  deflexion  of 
the  forearm  is  also  lost,  or  it  may  be  even  inclined  slightly  inwards. 
This  phenomenon  is  explained  by  the  position  of  the  epicondyle,  upon 
which  the  greater  sigmoid  cavity  now  rests,  allowing  the  ulna  to 
overlap  a  little  upon  the  humerus ;  rendering  the  forearm  actually 
somewhat  shorter  along  its  ulnar  margin,  although  the  head  of  the 
radius  may  still  occupy  the  summit  of  the  trochlea. 

If  the  bones  are  displaced  upwards  as  well  as  inwards,  a  consider- 
able shortening  is  declared,  and  the  head  o^  the  radius  may  now  be 
felt  behind  the  trochlea,  or  over  the  olecranon  fossa.  In  three  of  the 
four  examples  seen  by  Malgaigne,  all  of  them  ancient,  the  forearm  was 
in  a  state  of  supination.  Other  surgeons  have  met  with  cases  in  which 
the  forearm  was  supine,  but  they  must  be  considered  as  exceptions  to 
the  rule. 

The  following  example  of  this  dislocation,  unreduced  after  the  lapse 
of  fourteen  years,  is  reported  to  me  by  Dr.  T.  H.  Squier,  of  Elmira, 
N.  y. :  Thomas  Cook,  now  in  his  nineteenth  year,  was  four  years  and 
ten  months  old  when  he  fell  from  a  pile  of  boards  about  as  high  as 
a  man's  shoulder.  According  to  his  statement,  given  at  the  time,  his 
right  arm  caught  between  the  boards,  and,  in  falling,  he  turned  a 
summersault.  The  mother,  to  whom  the  child  immediately  ran, 
grasped  bis  arm  which  he  said  was  broken,  and  found  that  it  would 


Most  frerjuent  form  of 
incomplete  inward  dislo- 
catiou  of  the  forearm. 


604  DISLOCATIONS    OF    THE    RADIUS    AND    ULNA. 

roll  and  turn  in  various  ways.  When  the  surgeon  arrived,  three 
hours  afterwards,  the  arm  was  very  much  swollen  and  the  accident 
was  supposed  to  be  a  fracture.  At  present  flexion  and  extension  are 
perfect.  The  forearm  has  an  inward  deflection  of  a  hand's  breadth 
more  than  the  other.  The  power  of  pronation  is  complete,  but  the 
forearm  and  hand  cannot  be  supinated  entirely.  The  external  con- 
dyle is  very  prominent,  but  the  internal  is  almost  hid  by  the  olecranon, 
which  projects  inwards  nearly  as  far  as  the  point  of  the  epicondyle. 
The  finger  can  be  laid  in  the  olecranon  fossa  behind,  and  all  the  back 
part  of  the  trochlea  can  be  distinctly  traced.  By  flexing  the  forearm 
slowly  as  it  approaches  a  right  angle,  the  tendon  of  the  triceps  may 
be  felt,  lodged,  as  it  were,  on  the  back  part  of  the  point  of  the  epicon- 
dyle; and  by  continuing  the  flexion,  the  tendon  suddenly  slips  over  this 
point  and  places  itself  on  the  anterior  aspect  of  the  arm.  When  the 
forearm  is  fully  flexed,  the  tendon  is  advanced  full  three-quarters  of 
an  inch  in  front  of  the  epicondyle.  The  arm  is  very  serviceable,  but 
invariably  pains  him  after  a  hard  day's  work. 

Prognosis. — Malgaigne  was  unable  to  reduce  the  dislocation  in  a 
recent  case  of  incomplete  internal  dislocation,  which  came  under  his 
own  notice.  Triquet  succeeded  in  a  child  seven  years  old,  on  the 
fifteenth  day,  after  many  trials ;  but  the  movements  of  the  elbow-joint 
were  never  restored.  Dubruyn  succeeded  on  the  fifth  day,  but  not 
without  difficulty;  the  case  reported  by  Squier  was  mistaken  for  a 
fracture,  and  no  attempt  at  reduction  was  made;  and  in  the  only  re- 
maining example  which  has  been  put  upon  record,  the  precise  cha- 
racter of  the  accident  having  been  determined  by  Velpeau,  reduction 
was  easily  accomplished,  and  on  the  eighth  day  the  patient  was 
dismissed.^ 

Of  the  four  examples  of  inward  and  backward  luxation  seen  by 
Malgaigne,  not  one  was  ever  reduced ;  but  as  the  history  of  them  all 
is  not  complete,  it  is  by  no  means  to  be  inferred  that  reduction  could 
not  have  been  easily  accomplished,  at  least  in  some  of  them,  at  the 
first.  Nor,  with  such  imperfect  details  before  us,  can  we  understand 
fully  what  complications  may  have  existed,  such  as  would  perhaps 
render  these  exceptional,  rather  than  illustrative  examples. 

One  of  these  patients  had  a  completely  anchylosed  elbow  at  the 
end  of  two  years,  but  pronation  and  supination  were  preserved.  In 
the  case  of  another,  however,  even  flexion  and  extension  were  as  per- 
fect as  in  the  normal  condition. 

Treatment. — The  indications  of  treatment  are  the  same  as  in  dislo- 
cations outwards,  with  only  such  slight  modifications  as  the  judgment 
of  every  surgeon  must  naturally  suggest.  I  prefer  to  employ  by  way 
of  illustration  the  example  diagnosticated  by  Velpeau. 

On  the  10th  of  May,  1848,  Alexandrine  Guyot,  aet.  22,  entered  the 
Hospital  of  La  Charite,  with  an  incomplete  inward  dislocation  of  the 
forearm  which  had  just  occurred.  The  hand  and  forearm  were  in  a 
state  of  forced  pronation,  half-flexed,  and  the  whole  limb  from  the 
elbow  downwards  was  deflected  inwards.     There  were  present  also 

'  Denuce,  op.  cit.,  pp.  154-156. 


DISLOCATION    OF    EADIUS    AND    ULNA    FORWAEDS.      605 

all  the  other  usual  signs  of  this  dislocation,  and  Yelpeau  had  no  doubt 
as  to  its  true  character. 

In  order  to  accomplish  reduction,  one  assistant  made  counter-exten- 
sion upon  the  arm,  while  a  second  made  direct  extension  upon  the 
forearm.  At  first  the  tractions  were  made  in  the  direction  of  the  fore- 
arm (flexed  and  prone),  but  gradually  the  arm  was  straightened  and 
supinated.  Then  the  surgeon,  seizing  with  one  hand  the  superior  ex- 
tremity of  the  forearm,  and  with  the  other  the  inferior  extremity  of 
the  arm,  acted  forcibly  upon  the  two  portions  in  opposite  directions, 
and  immediately  the  reduction  was  effected  with  a  noise.^ 

§  4.  Dislocation  of  the  Radius  and  Ulna  Forwards. 

Sir  Astley  Cooper,  Vidal  (de  Cassis),  and  others  have  denied  that 
this  dislocation  was  possible  without  a  fracture  of  the  olecranon  pro- 
cess ;  but  Monin,  Prior,  Velpeau,  Canton,^  and  Denuc^  have  each  re- 
ported one  example,  so  that  its  existence  may  now  be  considered  as 
established.  Nevertheless,  it  is  only  as  a  result  of  very  violent  and 
extraordinary  accidents,  by  which  the  forearm  is  forcibly  flexed,  or 
greatly  extended,  or  twisted,  or  in  some  other  unusual  and  indirect 
way  the  olecranon  is  placed  in  front  of  the  humerus. 

Wis.  259. 


E.  Canton's  case  of  dislocation  of  the  radius  and  ulna  forwards. 

The  following  is  a  summary  of  the  facts  in  Velpeau's  case.     Alex- 
andrine Carelli,  set.  23,  was  knocked  down  by  a  carriage,  on  the  first 

'  Deuuce,  op.  cit.,  p.  155.  ^  Dub.  Quart.  Jouru.  of  Med.  Sci.,  Aug.  18G0. 


606  DISLOCATIONS    OF    THE    WRIST; 

of  July,  1848,  the  wheel  passing  over  the  right  arm.  The  arm  was 
found  in  a  right-angled  position,  and  it  could  neither  be  flexed  nor 
extended;  the  forearm  was  strongly  supinated ;  the  projecting  angle 
usually  made  by  the  olecranon  process  was  replaced  by  the  irregular 
extremity  of  the  humerus ;  the  forearm  was  shortened  upon  the  arm ; 
the  head  of  the  radius  resting  in  the  coronoid  fossa,  and  the  olecranon 
process  being  also  carried  upwards  and  a  little  outwards.  Eeduction 
was  easily  accomplished,  and  the  patient  left  on  the  nineteenth  day, 
with  only  a  slight  remaining  stiffness  in  the  joint.' 

A  case  is  reported  to  have  come  under  the  observation  of  Mr.  J.  "W. 
Langmore,  house  surgeon  at  the  University  College  Hospital,  London. 
It  was  occasioned  by  a  fall  upon  the  elbow.  The  reduction  of  the 
ulna  was  easily  accomplished  by  placing  the  knee  in  the  bend  of  the 
elbow  and  flexing  the  arm.  The  radius  was  then  reduced  by  pressure 
and  extension.^ 

Chapel  has  reported  a  case  of  dislocation  forwards  and  outwards, 
which  he  readily  reduced  soon  after  it  occurred,  while  Colson,  Leva, 
and  Guyot  have  each  reported  one  example  of  5w5-luxation  forwards, 
in  which  the  extremity  of  the  olecranon  process  has  been  found  rest- 
ing upon  the  extremity  of  the  humeral  trochlea.^ 

Treatment. — If  the  dislocation  is  complete,  and  the  forearm  is  short- 
ened and  flexed  upon  the  arm,  the  reduction  should  be  first  attempted 
by  violent  flexion,  or  by  flexion  combined  with  extension  from  the 
wrist,  and  counter-extension  from  the  lower  portion  of  the  humerus. 
If  the  dislocation  is  incomplete,  and  the  forearm  is  extended  upon  the 
arm,  the  reduction  may  be  readily  accomplished  by  extension  alone, 
or  by  moderate  flexion. 


CHAPTEK    X. 

DISLOCATIONS  OF  THE  WRIST  (RADIO-CARPAL  ARTICULATION). 

Eegarded  as  an  accident  of  not  unusual  occurrence  by  Hippocrates, 
J.  L.  Petit,  Duverney,  Boyer,  and  by  most  if  not  all  of  the  older  writers, 
its  frequency  began  to  be  questioned  by  Pouteau,  and  finally  its  ex- 
istence was  almost  absolutely  denied  by  Dupuytren,  who  remarks : 
"  I  have  for  a  long  time  publicly  taught  that  fractures  of  the  carpal 
end  of  the  radius  are  extremely  common;  that  I  had  always  found 
these  supposed  dislocations  of  the  wrist  turn  out  to  be  fractures  ;  and 
that,  in  spite  of  all  which  has  been  said  upon  the  subject,  I  have  never 
met  with,  or  heard  of,  one  single  well-authenticated  and  convincing 
case  of  the  dislocation  in  question."  Dupuytren  subsequently  de- 
clared that  he  would  not  positively  deny  the  possibility  of  the  acci- 

1  Denuc^,  op.  cit.,  p.  110. 

2  New  York  Med.  Record,  March  1,  18G7,  from  tlie  London  Lancet. 

3  Denuce,  p.  120. 


DISLOCATIONS    OF    THE    WRIST.  607 

dent,  yet  that  "it  must  at  least  be  admitted  that  the  accident  is  an 
extremely  rare  one."  Wishing  to  explain  this  infrequency,  he  says: 
"In  examining  the  structure  of  the  soft  parts,  one  cannot  fail  to  per- 
ceive that  it  is  not  the  ligaments  which  prevent  the  displacement  of 
the  articular  surface  forwards,  but  that  this  effect  is  especially  due  to 
the  multitude  of  flexor  tendons,  deprived  as  they  are  at  this  point  of 
all  the  fleshy  parts,  and  reduced  to  the  simple  fibrous  tissue  which 
composes  them.  These  tendons  are  bound  together  beneath  the  ante- 
rior annular  ligament  of  the  wrist,  and  thus  ofter  so  efficient  a  resist- 
ance that  severe  falls  are  insufficient  to  tear  them  through ;  the  hand 
is  forced  into  a  state  of  extreme  tension,  and  the  tendons  are  firmly 
applied  on  the  anterior  part  of  the  radio-carpal  articulation.  If  the 
extension  is  still  further  augmented,  the  wrist-joint  is  yet  more  closely 
clasped  by  these  parts,  and  their  power  of  resistance  is  incalculable  ; 
I  am  convinced  that  a  force  equivalent  to  one  thousand  pounds  weight 
would  be  inadequate  to  overcome  it;  and  the  known  power  of  the 
tendo  Achillis  is  sufficient  to  prove  that  this  computation  is  not  ex- 
aggerated. 

"  The  risk  of  dislocation  backwards  by  a  fall  on  the  dorsal  surface 
of  the  hand  is  equally  precluded  by  the  tendons  of  the  extensor  mus- 
cles. Their  arrangement  and  relations  at  the  back  of  the  joint  are 
similar;  it  is  true,  they  are  not  quite  so  strong;  but  we  must  admit 
that  their  power  of  resistance  is  very  considerable,  when  we  take  into 
consideration  how  they  are  inclosed  in  sheaths  as  they  cross  beneath 
the  posterior  annular  ligament  of  the  wrist,  I  have  not  alluded  to  the 
ulna,  for  it  has  really  little  or  nothing  to  do  with  these  movements,  as 
it  does  not  articulate  (directly)  with  the  hand. 

"  To  sum  up,  then,  the  extreme  rarity  of  dislocation  forwards  or 
backwards  is  owing  to  the  obstacles  opposed  by  the  flexor  or  extensor 
tendons." 

The  opinion  of  such  a  writer  as  Dupuytreu,  whose  experience  was 
very  great,  and  who  described  only  what  he  had  seen,  is  always  en- 
titled to  profound  respect;  yet  it  has  been  the  practice  of  nearly  all 
who  have  made  any  reference  to  his  opinions  in  this  matter  to  speak 
of  them  lightly,  and  not  a  few  have  falsely  represented  him  as  saying 
that  such  a  dislocation  was  "impossible."  The  fact  is,  that  surgeons 
do  still  constantly  mistake  fractures  of  the  lower  end  of  the  radius 
for  dislocations,  as  my  own  personal  observation  can  attest ;  and  not- 
withstanding examples  have  been  reported  by  Rene,  Marjolin,  Padieu, 
Cruveilhier,Yoillemier,  Boinot,  Malgaigne,Scoutetten,  Bransby  Cooper, 
Fergusson,  W.  Parker,  and  others,  yet  the  whole  number  of  cases  for 
which  the  distinction  is  claimed  is,  to  this  day,  so  inconsiderable  as 
only  to  establish  the  value  and  accuracy  of  Dupuytren's  opinion  that 
the  "  accident  is  an  extremely  rare  one."  But  it  is,  perhaps,  most  re- 
markable that  while  very  few  of  these  supposed  examples  have  been 
verified  by  an  autopsy,  in  every  instance  in  which  the  autopsy  has 
been  made,  the  dislocation  has  been  found  to  be  complicated  with  a 
fracture,  generally  of  the  lower  extremity  of  the  radius  or  of  the 
styloid  apophysis  of  the  ulna. 

The  existence  of  a  complication,  however,  does  not  render  the  acci- 


608  DISLOCATIONS    OF    THE    WRIST. 

dent  any  the  less  a  dislocation,  although  it  may  render  the  diagnosis 
more  difficult,  and  modify  somewhat  the  indications  of  treatment.  A 
knowledge  of  the  fact,  also,  that  such  complications  have  always  been 
observed  in  the  autopsy,  may  leave  us  in  doubt  as  to  what  is  the  natu- 
ral history  of  a  simple,  uncomplicated  dislocation,  if,  indeed,  it  does 
not  warrant  a  suspicion  that  such  a  case  never  occurs.  We  shall, 
nevertheless,  after  a  careful  analysis  of  the  cases  as  they  have  been 
reported,  and  by  a  consideration  of  the  anatomy  of  this  articulation, 
be  able  to  determine  with  some  degree  of  accuracy,  perhaps,  what 
are,  or  what  ought  to  be,  the  usual  causes,  signs,  treatment,  &c.,  of  these 
accidents. 

Partial  luxations  have  also  been  frequently  described  by  surgeons. 
I  have  never  met  with  an  example,  but  the  following  case,  related  to 
me  by  the  patient  himself,  I  believe  to  have  been  a  case  in  point. 

Lewis  C,  of  Buffalo,  set.  18,  by  a  fall  upon  his  hand,  broke  the  left 
forearm  below  the  middle,  and  at  the  same  time,  as  he  affirms,  par- 
tially dislocated  the  carpal  bones  backwards.  Dr.  Spaulding,  of 
Williamsville,  N.  Y.,  took  charge  of  the  limb,  and  pronounced  it  a 
fracture  with  partial  dislocation,  and  for  more  than  a  year  after  the 
accident  the  bones  had  a  tendency  to  become  displaced  in  the  same 
direction.  Whenever  he  attempted  to  lift  even  the  weight  of  half  a 
pound,  with  his  hand  supinated  and  his  forearm  extended  horizon- 
tally, the  lower  end  of  the  radius  would  spring  suddenly  forwards, 
and  all  power  in  the  arm  would  be  lost.  When  this  happened,  as  it 
did  quite  often,  he  always  reduced  the  bones  himself,  by  simply  push- 
ing upon  them  in  the  direction  of  the  articulation. 

Fourteen  years  after  the  accident,  I  examined  the  arm  and  found  it 
in  all  respects  perfect,  except  that  the  forearm  was  shortened  about 
one-third  of  an  inch,  which  shortening  was  due,  no  doubt,  to  the 
overlapping  of  the  broken  bones. 

§  1.  Dislocations  of  the  Carpal  Bones  Backwards. 

Causes. — The  same  casualty,  namely,  a  fall  upon  the  palm  of  the 
hand,  which,  as  we  have  elsewhere  noticed,  produces  frequently  a  frac- 
ture of  the  lower  end  of  the  radius,  occasionally  a  dislocation  of  the 
radius  and  ulna  backwards,  at  the  elbow-joint,  may  also,  it  is  believed, 
occasion  sometimes  a  dislocation  of  the  carpal  bones  backwards.  la 
several  of  the  cases  reported,  this  cause  has  been  assigned ;  but  in  the 
only  example  of  simple  dislocation  which  has  ever  come  under  my 
notice,  and  which  I  have  every  reason  to  believe  was  a  simple  dislo- 
cation unaccompanied  with  a  fracture,  the  carpal  bones  were  thrown 
back  by  a  fall  upon  the  back  of  the  hand.  The  following  is  a  brief 
account  of  the  case : — 

The  Rev.  Stephen  Porter,  of  Geneva,  K  Y.,  set.  75,  while  walking 
with  his  son  after  dark,  and  holding  in  his  right  hand  a  satchel,  slipped 
and  fell.  In  the  effiart  to  save  himself,  and  still  retaining  his  grasp 
upon  the  satchel,  his  right  hand  struck  the  side-walk  flexed,  and  in 
such  a  way  as  that  the  whole  force  of  the  fall  was  received  upon  the 
back  of  the  hand  and  wrist,  thus  throwing  the  hand  into  a  state  of 


DISLOCATIONS    or    THE    CARPAL    BONES    BACKWARDS.      609 

extreme  flexion.  In  less  than  twenty  minutes  he  was  at  my  house. 
No  swelling  had  yet  occurred,  and  the  moment  I  looked  at  the  wrist 
I  said  to  him,  "You  have  broken  your  arm;"  so  much  did  it  resemble 
a  fracture  of  the  lower  end  of  the  radius.  A  further  examination  led 
me  to  a  different  conclusion.  The  palmar  surface  of  the  wrist  pre- 
sented an  abrupt  rising  near  the  radio-carpal  articulation,  the  summit 
of  which  was  on  the  same  plane  and  continuous  with  the  bones  of  the 
forearm,  and  a  corresponding  elevation  existed  upon  the  dorsal  surface 
terminating  in  the  carpal  bones  and  hand ;  the  hand  was  slightly 
inclined  backwards,  but  the  fingers  were  moderately  flexed  upon  the 
palm.  To  this  extent  the  accident  bore  the  features  of  a  fracture  of 
the  radius;  but  the  hand  did  not  fall  to  the  radial  side;  the  projec- 
tions upon  the  palmar  and  dorsal  surfaces  were  more  abrupt  than  I 
had  ever  seen  in  a  case  of  fracture,  and  which,  if  it  were  a  fracture, 
would  imply  that  the  broken  extremities  had  been  driven  off"  from 
each  other  completely ;  the  most  salient  angles  of  these  projections 
were  abrupt,  but  not  sharp  or  ragged  ;  the  styloid  apophyses  could  be 
distinctly  felt,  and  I  was  not  only  able  to  determine  that  they  were 
not  broken,  but,  by  observing  their  relations  to  the  palmar  and  dorsal 
eminences,  it  was  easy  to  see  that  these  latter  corresponded  to  the 
situation  of  the  articulation. 

In  addition  to  these  evidences  that  I  had  to  deal  with  a  dislocation, 
and  not  a  fracture,  we  had  the  testimony  furnished  by  the  reduction, 
which  was  not  made,  however,  until  by  every  possible  means  the 
diagnosis  was  definitely  settled.  Seizing  the  hand  of  the  gentleman 
with  my  own  hand,  palm  to  palm,  and  making  moderate  but  steady 
extension  in  a  straight  line,  the  bones  suddenly  resumed  their  places 
with  the  usual  sensation  or  sound  accompanying  reductions.  There 
was  no  grating,  or  chafing,  or  crushing,  nor  was  the  reduction  accom- 
plished gradually,  but  suddenly.  To  test  still  further  the  accuracy 
of  the  diagnosis,  I  now  pressed  forcibly  upon  the  wrist  from  before 
back,  but  without  producing  any  degree  of  displacement,  nor  could 
any  crepitus  still  be  detected.  No  splint  was  applied,  and  on  the  fol- 
lowing morning  Mr.  Porter  preached  from  one  of  the  pulpits  in  the 
city,  only  retaining  his  arm  in  a  sling. 

Sixteen  months  after  the  accident,  Sept.  15,  1858,  this  gentleman 
again  called  upon  me,  and  I  found  the  arm  perfect  in  all  respects, 
except  that  it  was  not  quite  as  strong  as  before ;  the  lower  extremity 
of  the  ulna  was  preternaturally  movable,  and  occasionally  he  felt  a 
sudden  slipping  in  the  radio-carpal  articulation. 

Pathological  Anatomy. — In  the  examples  of  compound  or  compli- 
cated dislocations,  which  alone  have  been  exposed  by  dissections,  the 
posterior  and  lateral  ligaments  have  been  found  extensively  torn,  as 
also  frequently  the  anterior  ligament,  with  or  without  separation  of 
the  radial  or  ulnar  apophyses;  the  extensor  muscles  torn  up  from  the 
lower  part  of  the  forearm  and  displaced ;  the  first  row  of  the  carpal 
bones  lying  underneath  the  tendons,  and  upon  the  bones  of  the  fore- 
arm, sometimes  having  been  carried  directly  upwards,  sometimes  up- 
wards and  a  little  inwards,  and  at  other  times  upwards  and  outwards  ; 
the  arteries  and  nerves  have  occasionally  escaped  serious  injury,  but 
more  often  they  have  been  displaced,  bruised,  or  torn  asunder. 


610 


DISLOCATIONS    OF    THE    WRIST. 
Fiff.  200. 


Dislocation  of  the  carpal  bones  backwards.     (From  Fergusson.) 

Such  are,  briefly,  the  pathological  circumstances  which  may  be 
supposed  to  exist,  also,  in  a  lesser  or  greater  degree,  in  nearly  all 
cases  of  simple  dislocations. 

In  compound  dislocations,  however,  the  muscles,  or  rather  the  ten- 
dons, are  twisted,  torn,  and  thrust  aside,  producing  very  extensive 
lesions  among  the  deeper  structures  of  the  forearm  and  hand  before 
the  integuments  can  be  made  to  yield. 

On  the  2d  of  May,  1852,  Silas  Usher,  mt.  54,  had  his  right  arm 
caught  between  the  bumpers  of  two  cars,  bruising  the  hand  and  dis- 
locating the  carpal  bones  backwards,  the  radius  and  ulna  being  thrown 
forwards  and  pushed  completely  through  the  skin  into  the  palm  of  the 
hand.  Most  of  the  flexor  tendons  had  been  merely  thrust  aside,  but 
one  or  two  were  torn  asunder;  the  median  nerve  was  torn  off',  but  the 
radial  and  ulnar  nerves  were  apparently  uninjured,  and  there  was 
no  fracture.  The  patient  being  a  temperate  man,  in  perfect  health, 
and  the  bones  having  been  easily  replaced  by  moderate  extension,  it 
was  determined  to  make  an  effort  to  save  the  arm.  The  limb  was 
therefore  laid  on  a  carefully  padded  splint,  and  cool  water  lotions  dili- 
gently applied.  Phlegmonous  erysipelas  began  to  develop  itself  on 
the  third  day;  and  on  the  ninth,  gangrene  having  attacked  the  limb, 
I  amputated  a  little  above  the  middle  of  the  humerus.  On  the  four- 
teenth day  hemorrhage  occurred  suddenly  from  the  stump,  and  when 
I  reached  him  he  was  pulseless  and  dying. 

The  result  demonstrated  the  error  of  the  attempt  to  save  the  limb 
without  resection  of  the  lower  ends  of  the  bones  of  the  forearm. 

Si/mj^tovis. — The  usual  signs  have  already  been  sufficiently  stated 
in  the  example  which  we  have  given.     The  most  important  diagnostic 

marks  are  found  in  the  abruptness 
Fig.  261.  of  the  angles  formed  by  the  pro- 

jecting bones ;  the  relation  of  these 
prominences  to  the  styloid  apophy- 
ses; in  the  total  absence  of  crepi- 
tus ;  and  in  the  reduction,  which  is 
accomplished  easily,  suddenly,  and 
with  a  characteristic  sensation.     If 

Dislocation  of  the  carpal  bones  backwards.         SL  fraCtUrC  Complicates   the  aCcidcnt, 


DISLOCATIONS    OF    THE    CARPAL    BONES    FORWAEDS.      611 

crepitus  may  also  be  present.  It  should  be  remembered,  moreover, 
that  when  the  styloid  process  of  the  radius  is  broken,  if  the  hand  is 
moved  backwards  and  forwards  this  process  will  move  also,  which 
might  lead  to  the  supposition  that  the  radius  was  broken  higher  up, 
and  that  it  was  not  a  dislocation  at  all. 

Prognosis. — In  compound  dislocations  the  prognosis  is  exceedingly 
grave,  unless  the  surgeon  determines  to  resort  to  amputation,  or,  what 
is  generally  much  preferable,  to  resection.  In  dislocations  complicated 
with  fracture  of  the  posterior  edge  of  the  articulating  surface  of  the 
radius  ("Barton's  fracture'"),  some  difficulty  may  be  experienced  in 
retaining  the  bones  in  place ;  but  when  this  fracture  does  not  exist, 
the  posterior  margin  of  the  articulation,  considerably  elevated  above 
its  anterior  margin,  constitutes  a  suf&cient  protection  against  a  reluxa- 
tion  in  that  direction.  In  all  cases,  also  complicated  with  fracture, 
even  of  an  apophysis,  intense  inflammation  and  swelling  are  likely  to 
follow,  and  the  danger  of  a  permanent  anchylosis  is  greatly  increased. 

Treatment. — Extension  in  a  straight  line  has  generally  been  found 
sufficient  to  accomplish  the  reduction ;  to  which  may  be  added  a  slight 
rocking  or  lateral  motion,  if  necessary. 

The  reduction  may  be  effected  also  by  pressing  the  hand  backwards, 
while  the  surgeon  pushes  the  carpus  downwards  from  behind  and 
above,  in  the  direction  of  the  articulation. 

Unless  a  tendency  to  displacement  exists,  no  splints  or  bandages 
of  any  kind  ought  to  be  applied,  but  it  should  be  treated  by  rest  and 
cool  water  lotions  until  all  danger  from  inflammation  has  passed. 


§  2.  Dislocations  of  the  Carpal  Bones  Forwards. 

The  causes,  mechanism,  symp-  Fig.  263. 

toms,  pathology,  treatment,  &c., 
of  this  accident  i-esemble  in  so 
many  points  those  of  the  pre- 
ceding dislocation,  with  only 
the  differences  necessarily  due 
to  a  change  in  the  direction  of 
the  bones,  that  I  find  it  not  worth 
while  to  do  more  than  to  relate 
one  single  example  contained  in 
Bransby  Cooper's  edition  of  Sir 
Astley's  work  on  Fractures  and 
Uislocatio7is.  The  case  did  not 
come  under  the  observation  of 
Mr.  Cooper  himself,  but  was  re- 
lated to  him  by  Mr.  Haydon,  a 

surgeon  residing  in  London.  It  is  especially  interesting  as  furnishing 
an  example  of  a  dislocation  of  both  wrists  at  the  same  moment,  and 
from  similar  causes,  but  in  opposite  directions. 

A  lad,  aged  about  thirteen  years,  was  thrown  violently  from  a  horse 


Uislocatiou  of  the  carpal  bones  forwards. 


Philadelphia  Medical  Examiner,  1838. 


612         DISLOCATIONS    OF    THE    LOWEE    EXD    OF    ULNA. 

on  the  11th  of  June,  1840,  striking  upon  the  palms  of  both  hands 
and  upon  his  forehead.  The  left  carpus  was  found  to  be  dislocated 
backwards,  the  radius  lying  in  front  and  upon  the  scaphoides  and 
trapezium.  The  right  carpus  was  dislocated  forwards,  the  radius  and 
ulna  projecting  posteriorly,  and  the  bones  of  the  carpus  forming  an 
"irregular  knotty  tumor,  terminating  abruptly"  anteriorly. 

A  very  careful  examination  was  made  to  determine  what  parts 
came  in  contact  with  the  resisting  force,  but  although  the  palms  of 
both  hands  were  extensively  bruised,   there  was  not  the  slightest 

bruise  on  the  back  of  either  hand. 
Fig.  263.  Nor  were  the  gentlemen  present 

able  to  find  any  evidence  what-, 
ever  that  the  dislocation  was  ac- 
companied with  a  fracture.  "More- 
over," says  Mr.  Haydon,  "  we  were 
strengthened  in  our  opinion  that 
this  was  a  case  of  dislocation,  un- 
attended with  any  fracture,  because 
the  dislocations  appeared  so  perfect;  the  two  tumors  in  each  member 
so  distinct ;  the  reduction  so  complete ;  the  strength  of  the  parts  after 
reduction  so  great;  and  lastly,  by  the  very  trilling  pain  felt  after 
reduction,  for  within  an  hour  after,  the  patient  could  rotate  the  hand, 
and  supinate  it  when  pronated — this  could  not,  we  believe,  have 
been  done  had  there  existed  a  fracture." 


Dislocation  of  the  carpal  bones  forwards. 


CHAPTER   XI. 


DISLOCATIONS  OF  THE  LOWER  END  OF  THE  ULNA  (INFERIOR 
RADIO-ULNAR  ARTICULATION). 

In  connection  with  fractures  of  the  lower  end  of  the  radius  this 
accident  is  not  very  uncommon.  I  have  myself  met  with  it  under 
these  circumstances  several  times ;  but  without  a  fracture  it  is  quite 
rare.  Dupuytren  met  with  but  two  cases  in  his  long  and  extensive 
practice.  Sir  Astley  Cooper  does  not  record  a  single  instance,  and 
many  surgeons  affirm  that  they  have  never  seen  the  dislocation  in 
question. 

§  1.  Dislocations  op  the  Lower  End  op  the  Ulna  Backwards. 

To  the  eleven  or  twelve  examples  collected  and  referred  to  by 
Malgaigne,  I  am  only  able  to  add  two  cases  of  ancient  luxation  seen 
by  myself. 

Causes. — Duges  mentions  the  case  of  a  little  girl  in  whom  the  acci- 
dent occurred  in  both  arms,  but  at  different  periods,  by  being  lifted 
by  the  hands.  One  of  the  patientfe  seen  by  Desault,  a  child  five  years 
old,  had  the  ulna  dislocated  backwards  by  extension  accompanied  with 


PISLOCATIOXS    OF    LOWER    EXD    OF    ULNA    BACKWARDS.      613 

forced  pronation,  and  in  another  example,  cited  by  him,  forced  prona- 
tion alone,  as  in  wringing  wet  clothes,  was  found  to  have  been  sufficient. 
In  Hurteaux's  case  the  patient  had  fallen  upon  her  wrist. 

Pathological  Anatomy. — Rupture  of  the  synovial  .membrane  (sacci- 
form ligament),  and  also  of  the  ligament  which  binds  the  ulna  to  the 
cuneiform  bone :  the  little  head  or  lower  extremity  of  the  ulna  aban- 
doning its  socket  in  the  radius,  and  being  thrown  backwards,  or  in 
some  cases  backwards  and  outwards  so  as  to  cross  obliquely  the  lower 
end  of  the  radius;  or  it  may  incline  inwards  as  well  as  backwards. 

House  Surgeon  Owen,  of  Bellevue  Hospital,  called  my  attention, 
April  4,  1869,  to  an  example  of  this  dislocation  in  ward  28.  The 
patient,  Mary  Fay,  get.  27,  having  puerperal  mania,  was  confined, 
some  time  in  February,  in  a  strait-jacket,  and  the  accident  happened 
during  this  confinement,  about  six  weeks  before  she  came  under  my 
notice.  I  found  the  right  ulna  displaced  backwards  so  that  its  artic- 
ular surfaces  were  completely  separated  ;  but  it  did  not  override  the 
radius,  and  with  moderate  pressure  it  was  returned  to  place.  The 
dislocation  and  reduction,  which  had  been  frequently  made  by  the 
house  staff  since  the  accident,  caused  no  pain,  but  was  accompanied 
with  a  slight  grating  sensation. 

Dr.  Moore,  of  Rochester,  has  found  this  dislocation  existing  in  con- 
nection with  a  Colles  fracture.  In  the  chapter  on  fractures  of  the 
radius  I  have  made  especial  reference  to  the  views  of  this  distinguished 
surgeon  upon  this  subject. 

Several  examples  are  mentioned  also  in  which  the  end  of  the  bone 
has  been  thrust  completely  through  the  integuments. 

Prognosis. — In  recent  cases  the  reduction  has  generally  been  accom- 
plished without  difficulty,  and  in  only  three  or  four  instances  has  the 
bone  become  spontaneously  displaced. 

Loder  reduced  the  ulna  after  eight  weeks,  and  Rognetta  after  sixty 
days.  In  one  of  the  examples  to  which  I  have  already  referred  as 
having  been  seen  by  myself,  the  dislocation  had  existed  twenty  years, 
the  accident  having  occurred  in  Ireland  when  the  person  was  fifteen 
years  old.  When  I  examined  the  arm,  July  21,  1850,  the  right  ulna 
projected  backwards  and  a  little  outwards,  about  half  an  inch.  He 
said  he  had  been  lame  with  it  for  several  years,  but  the  motions  of  the 
wrist-joint  were  now  completely  restored,  and  both  pronation  and 
supination  were  perfect. 

Symptoms. — The  hand  is  usually  fixed  in  a  position  midway  between 
supination  and  pronation.  Boyer,  however,  found  the  hand  in  a  state 
of  extreme  pronation.  The  extremity  of  the  ulna  is  felt  and  seen 
distinctly  upon  the  back  of  the  wrist,  prominent  and  movable ;  and 
the  styloid  process  is  no  longer  in  a  line  with  the  metacarpal  bone  of 
the  little  finger;  the  fingers,  hand,  and  forearm  are  slightly  flexed. 

l^reaiment. — The  reduction  may  be  accomplished  by  holding  firmly 
upon  the  radius  and  at  the  same  moment  pushing  the  ulna  forcibly 
toward  its  socket ;  or  by  simply  supinating  the  hand  strongly.  Some 
cases  demand  also  extension  and  counter-extension. 

Generally  the  bone  has  been  found  to  remain  in  its  place  without 
assistance,  yet  in  three  or  four  of  the  examples  upon  record  the  con- 


614  DISLOCATIONS    OF    THE    LOWER    END    OF    ULNA. 

stant  tendency  to  displacement  when  the  pressure  was  removed  has 
rendered  it  necessary  to  employ  splints  and  compresses. 

§  2.  Dislocations  or  the  Lower  End  or  the  Ulna  Forwards. 

The  dislocation  forwards  is  said  by  Malgaigne  to  be  more  rare  than 
the  dislocation  backwards.  In  addition  to  the  nine  cases  collected  by 
him,  I  have  been  able  to  add  one  reported  by  Parker,  of  Liverpool ; 
leaving,  therefore,  a  difference  of  only  three  or  four  in  favor  of  the 
luxation  backwards ;  and  not  sufficient,  I  think,  to  warrant  any  posi- 
tive conclusions  as  to  the  relative  frequency  of  the  two  accidents. 

While  the  dislocation  backwards  is  usually  caused  by  violent  pro- 
nation of  the  hand,  this  dislocation  is  most  often  occasioned  by  violent 
supination.  The  hand  is  therefore  generally  found  to  be  supinated 
forcibly,  and  the  projection  formed  by  the  end  of  the  bone  is  seen  upon 
the  front  of  the  wrist  instead  of  the  back. 

By  pushing  the  ulna  toward  its  socket  while  an  attempt  is  made  to 
flex  the  hand,  or  by  extension,  supination,  &c.,  it  is  made  to  resume  its 
position  readily.  In  the  case  reported  by  Parker,  however,  the  re- 
duction was  effected  only  while  the  hand  was  pronated. 

Parker's  case,  already  referred  to,  is  thus  related: — ■ 

"John  Dalton,  aged  forty,  applied  to  the  hospital  Aug.  9th,  1841, 
under  the  following  circumstances: — 

"  States  that  he  is  a  carter,  and  falling  down,  the  shaft  of  the  cart 
fell  upon  his  hand  and  forearm,  in  such  a  way  as  to  supinate  them 
forcibly.  He  complains  of  pain  in  the  left  wrist.  The  forearm  is 
supinated,  and  cannot  be  pronated,  the  attempt  causing  much  suffering. 
The  wrist-joint  can  be  flexed  or  extended  without  much  pain.  On 
looking  at  the  back  of  the  wrist,  the  appearance  is  characteristic;  the 
natural  prominence  of  the  ulna  is  wanting  ;  an  evident  depression  ex- 
ists, as  if  the  lower  end  of  the  ulna  had  been  dissected  out;  it  can  be 
traced,  however,  on  a  plane  anterior  to  the  radius,  its  button-like  head 
being  distinctly  felt  under  the  flexor  tendons.  Several  ineffectual  and 
very  painful  attempts  were  made  to  accomplish  the  reduction,  by 
pushing  the  head  of  the  ulna  into  its  natural  situation.  This  was  at 
last  effected  by  seizing  the  hand  to  make  extension  (counter-extension 
being  made  at  the  elboAv),  then  forcibly  pronating  the  hand,  at  the 
same  time  pressing  backwards  the  dislocated  head  of  the  bone  with 
the  fingers  of  the  left  hand.  After  persevering  for  a  short  time,  the 
bone  was  felt  to  assume  its  natural  position,  the  wrist  acquired  its 
usual  appearance,  and  the  ordinary  movements  of  the  joint  could  be 
readily  performed.  There  was  no  tendency  to  redislocation,  and  the 
man  was  dismissed  with  directions  to  keep  the  bone  quiet,  and  to 
foment  it.  He  attended  as  an  out-patient  for  two  or  three  days,  after 
which,  complaining  of  nothing  but  a  little  weakness  in  the  part,  a 
bandage  was  applied,  and  ordered  to  be  worn  for  a  short  time.'" 

'  Parker,  Amer.  Joiirn.  3Ied.  Sci.,  April,  1843.  p.  470;  from  Lond.  and  Edin. 
Mouth.  Journ.  Med.  Sci.,  Dec.  1842. 


DISLOCATIONS    OF    THE    CAEPAL    BOXES.  615 


CHAPTER   XII. 

DISLOCATIONS  OF  THE  CARPAL  BONES  (AMONG  THEMSELVES). 

Bound  together  on  all  sides  by  strong  ligaments,  and  enjoying 
only  a  very  limited  degree  of  motion  among  themselves,  the  carpal 
bones  seldom  become  displaced  except  in  gunshot  wounds,  or  in  con- 
nection with  extensive  lacerations  and  fractures  of  the  neighboring 
parts.  Simple  dislocations,  or  rather  subluxations  of  these  bones,  do, 
however,  occasionally  take  place,  but,  so  far  as  we  have  been  able  to 
ascertain,  only  in  one  direction,  namely,  backwards. 

The  bones  of  the  carpus,  which  are  said  occasionally  to  have  suf- 
fered simple  backward  subluxation,  are  the  semilunar,  cuneiform,  and 
pisiform  of  the  first  row,  and  the  magnum  of  the  second  row. 

Richerand,  the  editor  of  Boyer's  Lectures,  says  that  he  once  met 
with  a  subluxation  of  the  os  magnum  backwards,  of  which  he  has 
given  us  the  following  account :  "  Mrs.  B.,  in  a  labor  pain,  seized  vio- 
lently the  edge  of  her  mattress,  and  squeezed  it  forcibly,  turning  her 
wrist  forwards;  she  instantly  heard  a  slight  crack,  and  felt  some  pain, 
to  which  her  other  sufferings  did  not  allow  her  to  attend.  Fifteen 
days  afterwards,  happily  delivered,  and  recovered  by  the  care  of  Pro- 
fessor Baudelocque,  she  showed  her  left  hand  to  this  celebrated  ac- 
coucheur, and  expressed  her  disquietude  about  the  tumor  which 
appeared  on  it,  especially  when  much  bent.  I  was  called  to  visit  the 
lady.  I  found  that  this  hard  circumscribed  tumor,  which  disappeared 
almost  totally  by  extending  the  hand,  was  formed  by  the  head  of  the 
OS  magnum,  luxated  backwards;  I  replaced  it  entirely  by  extending 
the  hand,  and  making  gentle  pressure  on  it.  As  the  affection  did  not 
impede  the  motion  of  the  part,  as  the  tumor  disappeared  on  extend- 
ing the  hand,  and  as  it  would  have  been  but  little  apparent  in  any 
state  of  the  hand  had  Mrs,  B.  been  more  in  flesh,  I  advised  her  not 
to  be  uneasy  about  it,  and  to  apply  no  remedy  to  it."^ 

Richerand  adds  also  that  Boyer  and  Chopart  had  each  met  with 
the  same  dislocation. 

Bransby  Cooper  saw  the  os  magnum  displaced  backwards  in  a 
stout,  muscular  young  man,  by  a  fail  upon  the  back  of  the  hand  when 
in  extreme  flexion.  The  hand  remained  slightly  bent,  and  the  pro- 
jection of  the  OS  magnum  was  very  distinct.  Reduction  was  attempted 
by  extending  the  whole  hand,  at  the  same  time  making  pressure  upon 
the  displaced  bone;  this  not  succeeding,  extension  was  made  from  the 
middle  and  forefingers  only,  while  pressure  was  kept  up  on  the  os 
magnum,  when  suddenly  the  bone  resumed  its  natural  position.  On 
flexing  the  hand,  however,  the  dislocation  was  immediately  repro- 

'  Richerand,  Boyer's  Lectures  ou  Diseases  of  Boucs,  Amer.  ed.,  1S05,  p.  201. 


616  DISLOCATIONS    OF    THE    CAEPAL    BONES. 

duced;  and  it  became  necessary  to  apply  a  compress  and  splint.  For 
several  days  after,  he  was  in  the  habit  of  pushing  it  out  by  flexing 
the  hand,  in  order  that  the  young  men  at  Guy's  Hospital  might  see  its 
reduction ;  which  was  always  easily  accomplished  by  simple  pushing 
upon  it. 

Sir  Astley  says  that  both  the  os  magnum  and  cuneiform  are  some- 
times thrown  a  little  backwards,  from  simple  relaxation  of  the  liga- 
ments, producing  a  great  degree  of  weakness,  so  as  to  render  the  hand 
useless  unless  the  wrist  be  supported;  and  he  mentions  the  case  of  a 
young  lady  in  whom  the  os  magnum  was  thus  displaced,  and  who  was 
obliged  to  give  up  her  music  in  consequence;  for  when  she  wished  to 
use  her  hand,  slie  was  compelled  to  wear  two  short  splints,  made  fast 
to  the  back  and  forepart  of  the  hand  and  forearm.  Another  lady, 
whose  hand  was  weak  from  a  similar  cause,  wore,  for  the  purpose  of 
giving  it  strength,  a  strong  steel  chain  bracelet,  clasped  very  tightly 
around  the  wrist.^ 

Gras  has  described  a  dislocation  of  the  pisiform  bone,'  and  Fergus- 
son  says  he  has  known  an  example  in  which  this  bone  was  detached 
from  its  lower  connections  by  the  action  of  the  flexor  carpi-ulnaris.^ 
Little  benefit,  he  thinks,  can  be  expected  from  any  attempts  to  keep 
it  in  place  when  it  is  dislocated,  nor  is  its  displacement  of  much  con- 
sequence. Erichsen  thinks  he  has  seen  a  dislocation  of  the  os  lunare 
produced  by  a  fall  upon  the  hand  when  forcibly  flexed.  By  exten- 
sion and  pressure  it  was  easily  replaced,  but  when  the  hand  was  flexed 
the  dislocation  was  immediately  reproduced.^ 

Notwithstanding  that  Sir  Astley,  Miller,  and  others  have  taught 
that  the  cuneiform  bone  is  liable  to  displacement,  and  that  South  has 
affirmed  the  same  of  the  unciform,  I  have  found  no  account  of  an  ex- 
ample of  simple  dislocation  of  single  carpal  bones  except  in  the  cases 
of  the  OS  magnum,  pisiformis,  and  lunare,  as  above  mentioned. 

Maisonneuve  has  reported  an  example  of  simple  dislocation,  with- 
out wound  of  the  integuments,  at  the  middle  carpal  articulation.  A 
man  had  fallen  forty  feet,  and  was  carried  dying  to  the  Hotel  Dieu. 
The  symptoms  were  almost  precisely  those  of  a  dislocation  of  both 
rows  of  the  carpal  bones  backwards.  The  reduction  was  not  accom- 
plished during  life,  but  after  death  a  simple  effort  of  traction  was 
sufficient  to  replace  the  bones.  The  dissection  showed  that  the  bones 
of  the  second  row  were  almost  completely  separated  from  those  of  the 
first,  upon  which  they  were  overlapped  backwards.  A  small  frag- 
ment of  both  the  scaphoids  and  cuneiform  remained  attached  to  the 
second  row,  but  with  this  exception,  the  separation  was  complete.^ 

'  Sir  A.  Cooper,  op.  cit.,  p.  435. 

2  Note  to  Chelius,  by  South,  op.  cit.,  p.  234. 

3  Fergusson,  op.  cit.,  p.  190. 

*  Erichsen,  Science  and  Art  of  Surg.,  Amer.  ed.,  18.M),  p.  2o9. 

5  Maisonneuve,  Malgaigne,  op.  cit., "from  Mem.  de  la  Soc.  de  Cliirurg.,  t.  ii. 


DISLOCATION    OF    THE    METACARPAL    BONES.  617 


CHAPTER    XIII. 

DISLOCATION  OF  THE  METACARPAL  BONES  (AT  THE  CARPO- 
METACARPAL ARTICULATIONS:). 

The  metacarpal  bone  of  the  thumb  may  be  dislocated  either  back- 
wards or  forwards.  The  former  is  the  most  frequent ;  and  it  is  pro- 
duced generally  by  a  fall  upon  the  thumb,  which  throws  it  into  a  state 
of  extreme  flexion :  it  has  also  been  occasioned  by  a  force  acting  in 
an  opposite  direction,  as  when  a  flask  of  powder  is  exploded  in  the 
palm  of  the  hand,  or  a  blow  is  received  upon  the  extremity  and  palmar 
aspect  of  the  last  phalanx. 

The  dislocation  may  be  partial  or  complete.  In  the  few  examples 
of  partial  dislocation  which  have  been  recorded,  the  position  of  the 
finger  has  been  either  moderately  flexed  or  straight,  and  the  signs  of 
the  accident  have  been  occasionally  so  obscure  as  to  have  led  to  an 
error  in  the  diagnosis,  and  the  luxation  has  remained  unreduced. 
When  the  dislocation  is  recognized,  reduction  is  in  most  cases  easily 
accomplished  by  pressure,  combined  with  extension ;  after  which  it 
is  sometimes  necessary  to  apply  a  splint  to  maintain  the  apposition. 
If  the  reduction  is  not  accomplished,  the  joint  is  permanently  maimed. 

Complete  backward  luxations  are  more  frequent  than  incomplete, 
and  are  produced  by  the  same  class  of  causes ;  generally  by  a  fall  upon 
the  palmar  surface  of  the  thumb. 

The  symptoms  are  sufficiently  clear,  although  the  position  of  the 
thumb  is  not  always  the  same.  It  has  been  found  perfectly  straight, 
without  any  inclination  either  way,  or  flexed  more  or  less,  with  the 
metacarpal  bone  also  inclined  inwards  toward  the  palm.  The  motions 
of  the  joint  are  interrupted,  and  the  proximal  extremity  of  the  meta- 
carpal bone  riding  upon  the  back  of  the  trapezium,  projects  sensibly 
in  this  direction,  and  the  trapezium  is  also  felt  unusually  prominent 
under  the  thenar  eminence.  The  overlapping  varies  from  a  line  or 
two  to  three-quarters  of  an  inch.  In  the  patient  mentioned  by  Bour- 
guet,  the  head  of  the  metacarpal  bone  almost  reached  the  styloid  pro- 
cess of  the  radius. 

The  reduction  is  to  be  effected  by  extension  alone,  or  by  extension 
with  moderate  pressure. 

In  two  of  the  examples  reported,  although  the  reduction  was  accom- 
plished very  easily,  the  dislocation  was  reproduced  when  the  extension 
ceased,  and  it  became  necessary  to  apply  splints.  Malgaigne  did  not 
observe,  in  the  case  seen  by  him,  any  such  tendency  to  displacement. 

In  the  case  of  Bourguet's  patient  the  reduction  was  never  accom- 
plished, although  the  attempt  was  made  on  the  second  day  by  a  sur- 
geon, and  repeated  after  about  two  months  by  Bourguet  himself. 
40 


618  DISLOCATION    OF    THE    METACAKPAL    BOXES. 

Fergusson,  who  has  met  with  several  of  these  dislocations,  says  that 
he  has°seen  even  a  splint  and  roller  fail  of  keeping  the  bones  in  place; 
and  he  recommends,  for  the  purpose  of  security,  that  the  splint  should 
extend  some  distance  upon  the  forearm. 

Sir  Astley  Cooper  says  that,  in  the  cases  of  this  accident  which  he 
has  seen,  the  metacarpal  bone  of  the  thumb  has  been  thrown  inwards, 
between  the  trapezium  and  the  root  of  the  metacarpal  bone  supporting 
the  forefinger  ;  forming  a  protuberance  toward  the  palm  of  the  hand ; 
the  thumb°has  been  bent  backwards,  and  adduction  was  impossible. 

This  distinguished  surgeon  cites  no  examples,  nor  are  we  able  to 
find  upon  record  an  instance  of  complete  inward  dislocation  of  this 
bone,  such  as  Sir  Astley  has  described. 

Vidal  (de  Cassis)  believes  that  he  has  met  with  a  partial  forward  dis- 
location, which  he  reduced  readily,  but  the  patient  having  removed 
the  retentive  means,  the  dislocation  was  reproduced  and  the  bone  was 
not  again  replaced.^ 

Malgaigne  has  collected  only  three  examples  of  a  dislocation  of 
either  of  the  other  metacarpal  bones.  One,  observed  by  Bourguet, 
was  a  dislocation  forwards  of  the  metacarpal  bone  of  the  index  finger, 
having  been  caused  by  a  great  force  applied  to  the  back  of  the  phalanx 
near  the  carpus.  Seduction  was  effected  by  extension  and  pressure, 
the  bone  resuming  its  place  insensibly  and  not  suddenly.  With  the 
aid  of  splints  it  was  retained  in  position,  and  the  cure  was  perfect. 
The  second,  seen  by  Roux.  was  a  backward  luxation  at  the  carpo- 
metacarpal articulation  of  the  second,  or  great  finger,  produced  by  an 
explosion  in  a  mine.  By  pressure  made  directly  upon  the  projecting 
bone  he  was  unable  to  reduce  it,  but  by  uniting  pressure  with  exten- 
sion from  the  finger,  he  succeeded  readily.  After  the  reduction  was 
effected,  it  was  noticed  that  when  the  hand  was  straightened  the  bone 
became  reluxated,  but  that  it  was  easily  kept  in  place  when  the  hand 
w'as  flexed.  The  third  example  (occurring  in  the  same  joint),  men- 
tioned by  Malgaigne,  occasioned  by  a  fall  upon  the  clenched  hand, 
was  probably  incomplete,  and  Malgaigne  is  not  quite  certain  that  it 
was  not  a  fracture. 

The  following  very  instructive  case  of  forward  luxation  of  the  second 
metacarpal  bone  at  its  proximal  end,  has  been  reported  to  me  by  Dr. 
J.  Marsh,  Asst.  Surgeon  U.S.A. 

On  the  1st  of  April,  1868,  Corporal  Charles  C ,  set.  25,  was  struck 

accidentally  on  the  back  of  his  right  hand  by  a  hammer  weighing  seven 
pounds.  The  hand  was  at  the  time  firmly  clenched,  and  covered  with 
a  buckskin  glove.  The  blow  was  received  obliquely.  Dr.  Marsh  saw 
him  half  an  hour  after  the  accident.  A  marked  depression  was  readily 
discovered  on  the  back  of  the  hand,  corresponding  to  the  proximal 
end  of  the  bone,  and  from  this  point  a  gradual  elevation  of  the  bone 
could  be  traced  to  its  natural  level  at  the  distal  end.  On  the  palm  of 
the  hand  the  displacement  was  equally  manifest.  In  this  position  it 
was  fixed,  and  seemed  immovable.  It  was  easily  and  quickly  re- 
duced, however,  by  making  extension  from  the  fingers,  while  at  the 

'  Vidal  (de  Cassis),  Traite  de  Pathologic  Externe,  etc.,  3d  Paris  ed.,  t.  ii.  p.  564. 


DISLOCATION    OF    THE    METACAEPAL    BONES.  619 

same  moment  pressure  was  made  by  the  thumb  in  the  palm  of  the 
hand.  It  returned  to  its  place  with  the  usual  sensation  accompanying 
a  reduction  of  a  dislocation,  and  the  deformity  at  once  disappeared ; 
a  ball  of  tow  was  now  placed  in  the  palm  of  the  hand,  and  secured 
there  by  a  roller.  On  the  13th  of  April  he  returned  to  duty,  but  his 
hand  did  not  acquire  its  full  strength  for  some  time  longer. 

The  following  example  of  dislocation  of  all  the  metacarpal  bones, 
except  that  of  the  thumb,  is  probably  without  a  parallel.  Corporal 
Garrigan,  at  the  battle  of  Fredericksburg,  Dec.  13th,  1862,  while  hold- 
ing his  gun  at  "  ready,"  was  hit  by  a  ball  on  the  back  and  ulnar  side 
of  his  left  hand,  the  ball  traversing  the  back  of  the  hand  between  the 
last  row  of  carpal  bones  and  the  skin,  and  emerging  on  the  radial  side, 
sending  the  carpal  bones  forwards  and  dislocating  the  metacarpal 
bones  backwards.  Great  swelling  ensued,  and  the  nature  of  the  acci- 
dent was  not  known  for  some  months.  When  I  examined  the  hand, 
five  years  later,  the  displacement  was  very  conspicuous,  no  fragments 
of  bone  had  ever  escaped.  The  motions  of  all  the  fingers,  except  the 
index  and  little  fingers,  were  unimpaired. 

In  April,  1849,  Stephen  Peterson,  set.  24,  was  admitted  into  the 
Buffalo  Hospital  of  the  Sisters  of  Charity,  with  a  partial  dislocation 
backwards  of  the  proximal  ends  of  the  metacarpal  bones  of  the  index 
and  great  fingers  of  the  right  hand  ;  produced,  as  he  affirms,  by  striking 
a  man  with  his  clenched  fist,  about  one  year  previous.  He  says  that 
he  called  upon  a  surgeon  immediately,  but  he  was  unable  to  keep  the 
bones  in  place.  The  projection  was  very  manifest  at  the  time  of  my 
examination,  and  the  hand  had  never  recovered  the  power  of  grasp- 
ing bodies  firmly. 

During  the  same  year  I  found  in  the  hospital  a  precisely  similar  case, 
in  the  person  of  Francis  McCoit,  set.  32,  a  sailor,  which  had  occurred 
four  years  before,  in  consequence  of  a  blow  given  with  his  fist.  The 
same  bones  were  partially  displaced  backwards,  and  remained  unre- 
duced. This  man  had  also  consulted  a  surgeon  soon  after  the  injury 
was  received. 

In  both  of  the  above  examples  I  instituted  a  careful  examination  to 
determine  whether  it  was  not  the  bones  of  the  carpus  which  were 
thus  displaced  ;  but  the  result  was  conclusive  as  to  the  nature  of  the 
accident,  and  I  have  obtained  casts  of  both,  in  order  to  illustrate  par- 
tial dislocations  of  the  metacarpal  bones. 

In  1866  I  met  with  a  similar  case,  only  that  the  metacarpal  bone  of 
the  index  finger  was  alone  dislocated,  at  Bellevue  Hospital,  in  a  woman 
28  years  of  age,  caused  by  falling  upon  her  hand  with  the  fingers  closed.. 
Reduction  was  easily  eftegted. 


620      OF    FIRST    PHALANGES    OF    THUMB    AND    FINGERS. 


CHAPTER   XIV. 

DISLOCATIONS  OF  THE   FIRST  PHALANGES  OF  THE  THUMB  AND 
FINGERS  (AT  THE  METACARPO-PHALANGEAL  ARTICULATIONS). 


Fiff.  2G4. 


§  1.  Dislocations  of  the  First  Phalanx  of  the  Thumb  Backwards. 

This  bone  may  be  dislocated  backwards  or  forwards,  but  most  fre- 
quently the  dislocation  is  backwards.  I  have  met  with  the  backward 
dislocation  nine  times,  and  the  forward  twice. 

The  backward  dislocation  is  occasioned  generally  by  a  fall  or  blow 
upon  the  distal  end  and  palmar  surface  of  the  thumb;  the  proximal 
extremity  of  the  first  phalanx  sliding  back  upon  the  distal  extremity 
of  the  metacarpal  bone,  and  standing  oft'  from  it  at  an  angle,  the  last 
being  again  flexed  upon  the  first  phalanx  ;  mean- 
while the  distal  end  of  the  metacarpal  bone  is 
seen  projecting  strongly  in  the  palm  of  the  hand. 
(Fig.  264.) 

These  are  the  usual  signs  which  characterize 
this  accident,  and  they  are  always  sufticiently 
diagnostic.  In  a  few  cases,  however,  the  pha- 
langes have  been  found  extended  upon  the  meta- 
carpal bone  in  almost  a  straight  line.  I  have 
twice  found  them  in  this  position. 

The  reduction  is  sometimes,  in  recent  cases, 
accomplished  with  great  ease,  as  the  folio wiug 
examples  will  illustrate. 

A  servant-girl,  tet.  25,  fell  down  a  flight  of  steps 
Nov.  15th,  lb50,  striking  upon  the  inside  of  her 
right  hand  and  thumb.  When  I  saw  her,  only  a 
few  minutes  afterwards,  I  found  the  first  phalanx  standing  back  almost 
at  a  right  angle  with  the  metacarpal  bone,  and  the  second  phalanx 
also  flexed  to  a  right  angle  with  the  first.  Assisted  by  my  pupil, 
Mr.  Boardman,  the  reduction  was  effected  in  about  twenty  seconds,  by 
bending  the  first  phalanx  farther  back,  and  at  the  same  moment  press- 
ing the  proximal  end  of  this  phalanx  forwards  in  the  direction  of  the 
joint.  Without  employing  great  force,  the  reduction  took  place  sud- 
denly and  with  a  snap.  Yery  little  swelling  followed,  and  in  three 
weeks  she  was  able  to  use  her  needle  without  inconvenience. 

Michael  Wolfe,  set.  85,  fell  from  a  height,  causing  a  fracture  of  his 
left  arm,  and  a  dislocation  of  his  right  thumb  backwards.  I  saw  him 
within  two  hours  after  the  accident.  The  thumb  was  much  swollen, 
and  its  position  the  same  as  in  the  case  just  described.  Although 
Wolfe  was  a  strong,  muscular  man,  the  reduction  was  accomplished  in 
a  few  seconds  by  applying  over  the  last  phalanx  the  Indian  toy  called 


Dislocation  of  the  first 
phalanx  of  the  thumb  back- 
■wards. 


FIRST    PHALANX    OF    THE    THUMB    BACKWARDS.         621 

a  "puzzle,"  and  making  extension  in  a  straight  line,  wliile  an  assistant 
made  counter-extension  from  the  hand  and  wrist.  The  use  of  the  joint 
was  soon  completely  restored. 

Examples,  however,  are  constantly  occurring,  which  are  only  re- 
duced after  long-continued  and  painful  efforts,  or  which,  indeed,  com- 
pletely exhaust  the  patience  and  loaffle  the  skill  of  the  most  experienced 
surgeons. 

Mary  J.  S.,  set.  23,  fell  upon  her  right  hand  with  her  fingers  and 
thumb  extended,  in  Sept.  1853,  and  dislocated  this  bone  backwards. 
A  young  surgeon  attempted  to  reduce  the  dislocation  half  an  hour 
after  the  accident,  by  the  same  manoeuvre  adopted  by  myself  success- 
fully in  the  case  of  the  servant-girl ;  only  that  he  made  extension  upon 
the  last  phalanx  at  the  same  moment.  The  surgeon  believes  that  the 
bone  was  reduced,  but  one  week  later  he  found  it  displaced,  and,  as 
he  believes,  reduced  it  again.     The  same  thing  occurred  a  third  time. 

Six  months  after  this,  the  girl  consulted  m^e  to  ascertain  what  could 
be  done  for  her  relief.  The  thumb  occupied  the  usual  position,  and 
admitted  of  no  motion  except  at  the  carpo-metacarpal  articulation. 

It  is  quite  probable  that  the  dislocaticm  was  never  reduced,  an  error 
which,  if  it  did  occur,  might  easily  be  excused,  when  we  remember 
that  from  the  first  the  thumb  was  greatly  swollen. 

In  May,  1848,  having  been  called  to  see  Gr.  H.,  who  had  attempted 
suicide  by  cutting  his  throat,  my  attention  was  arrested  by  the 
appearance  of  his  left  thumb,  and  which  I  found  to  be  occasioned  by 
an  ancient  dislocation  of  the  first  phalanx  backwards.  The  accident 
had  occurred,  he  afterwards  told  me,  twelve  years  before,  in  conse- 
quence of  a  fall  while  wrestling.  A  very  respectable  country  surgeon 
was  called,  and  made  three  several  attempts  to  reduce  it,  but  failed. 

The  several  bones  of  the  thumb  occupied  their  usual  positions,  that 
is  to  say,  the  positions  which  they  usually  occupy  in  this  dislocation, 
yet  notwithstanding  the  almost  complete  anchylosis  of  the  phalangeal 
articulations,  and  the  awkward  encroachment  of  the  distal  end  of  the 
metacarpal  bone  upon  the  palm,  the  hand  was  quite  useful. 

In  Sept.  1864, 1  found  in  my  service  at  the  Charity  Hospital  (Black- 
well's  Island),  New  York,  an  unreduced  dislocation  of  this  kind  in  a 
girl.     The  surgeons  had  tried  to  reduce  it,  but  had  failed. 

On  the  25th  of  July,  1857,  Catharine  Ernst  was  brought  to  me,  by 
her  parents,  having  a  dislocation  of  the  first  phalanx  of  the  right  hand, 
which  had  already  existed  some  days,  and  upon  which  several  un- 
successful attempts  at  reduction  had  been  made.  The  dislocation  was 
backwards,  but  the  phalanges,  instead  of  standing  at  an  acute  or  right 
angle  with  each  other  and  with  the  metacarpal  bone,  as  is  usually  the 
case,  were  in  a  straight  line  with  each  other  and  parallel  with  the 
metacarpal  bone.  AVhether  this  phenomenon  existed  from  the  first, 
or  was  due  to  the  eftbrts  already  made  at  reduction,  I  could  not  deter- 
mine, but  the  same  thing  has  been  noticed  occasionally  by  other  sur- 
geons. The  first  phalanx,  moreover,  instead  of  being  placed  directly 
behind  the  metacarpal  bone,  occupied  a  position  upon  its  back  a  little 
to  the  radial  side  of  the  centre. 

During  quite  half  an  hour  I  made  continued  and  varied  attempts 


622      OF    FIRST    PHALANGES    OF    THUMB    AND    FINGERS. 

to  reduce  the  bone,  by  extension,  by  forced  dorsal  flexion,  and  by 
pressing  the  upper  end  of  the  first  phalanx  in  the  direction  of  the 
joint  while  pressure  was  made  against  its  lower  end  so  as  to  bring  it 
into  dorsal  flexion,  and  finally  by  calling  to  my  aid  the  "  puzzle"  and 
chloroform,  but  all  to  no  purpose. 

One  week  later  I  repeated  these  efforts,  and  with  no  better  success. 
The  parents  peremptorily  refused  to  allow  me  to  cut  the  lateral  liga- 
ments or  flexor  tendons,  so  the  bone  remains  unreduced. 

In  the  following  case  the  relative  position  of  the  bones  was  the 
same  as  in  the  preceding  case,  but  the  reduction  was  not  difficult. 

Bernard  Lawler,  ^t.  10,  was  admitted  to  Bellevue  Hospital  in  Jan. 
1864,  with  a  fracture  of  the  femur  and  other  severe  injuries.  The 
dislocation  of  the  thumb  was  not  noticed  until  the  ninth  day.  The 
reduction  was  then  easily  accomplished,  in  presence  of  the  class  of 
medical  students,  by  forced  backward  flexion. 

Surgical  writers  have  recorded,  from  time  to  time,  a  great  many 
cases  in  which  it  has  been  found  difficult  or  impossible  to  effect  re- 
duction; and  it  is  asserted  upon  the  authority  of  Bromfield,  quoted 
by  Hey,  that  the  extending  force  has  been  increased  to  such  an  amount 
as  to  tear  ofl'  the  last  phalanx  without  having  succeeded  in  reducing 
the  first;  but  while  surgeons  have  united  in  their  testimony  as  to  the 
exceeding  obstinacy  of  a  large  proportion  of  these  dislocations,  they 
are  far  from  being  agreed  as  to  the  source  of  the  difficulty. 

Sir  Astley  Cooper  finds  a  sufficient  explanation  in  the  six  short  and 
powerful  muscles  which  are  inserted  into  the  first  and  last  phalanx, 
and  especially  in  the  flexors.^  Hey  believes  the  resistance  to  be  in 
the  lateral  ligaments  between  which  the  lower  end  of  the  metacarpal 
bone  escapes  and  becomes  imprisoned.  Ballingall,  Malgaigne,  Erich- 
sen,  and  Vidal  (de  Cassis)  think  the  metacarpal  bone  is  locked  between 
the  two  heads  of  the  flexor  brevis,  or  rather  between  the  opposing 
sets  of  muscles  which  centre  in  the  sesamoid  bones,  as  a  button  is 
fastened  into  a  button-hole.  Pailloux,  Lawrie,  Michel,  Leva,  Blechy, 
and  Eoser  affirm  that  the  anterior  ligament  being  torn  from  one  of  its 

attachments,  falls  between  the  joint  sur- 
Fig.  265.  faces  and  interposes  an  eftectual  obstacle 

to  reduction.  Dupuytren  ascribes  the 
difficulty  to  the  altered  relations  of  the 
lateral  ligaments,  which  are  naturally 
parallel  to  the  axis  of  the  metacarpal 
bone,  but  which  are  now  placed  at  a 
right  angle;  to  the  spasm  of  the  muscles, 
and  to  the  shortness  of  the  member,  in 
consequence  of  which  the  force  of  exten- 
sion has  to  be  applied  very  near  to  the 
seat  of  the  dislocation.  Lisfranc  found 
in  an  ancient  luxation  the  tendon  of  the 
Clove  hitch.  long   flexor   so  displaced   inwards   and 

'  Lawrie,  of  Glasgow,  says  that  Sir  Astley  in  a  conversation  with  him  declared 
that  the  "sesamoid  hones"  were  the  sources  of  the  difficulty.  See  Amer.  Journ. 
Med.  Sci.,  vol.  xxii.  p.  230,  with  ohservations  and  experiments  by  Lawrie. 


FIRST    PHALANX    OF    THE    THUMB    BACKWARDS.         623 

entangled  behind  the  extremity  of  the  bone  as  to  prevent  reduction. 
Deville  discovered  in  an  autopsy  a  similar  displacement  of  this  tendon 
outwards.     Wadsworth  has  made  the  same  observation.^ 

The  modes  of  reduction  practised  and  recommended  by  these  dif- 
ferent surgeons  are  as  diversified  and  irreconcilable  as  their  views  of 
the  mechanism  and  pathological  anatomy  of  the  accident. 

Sir  Astley  Cooper  recommends  that  extension  shall  be  made  by 
bending  the  thumb  toward  the  palm  of  the  hand,  to  relax  the  flexor 
muscles  as  much  as  possible ;  and  then,  by  fastening  a  clove  hitch 
upon  the  first  phalanx,  previously  covered  with  a  piece  of  soft  leather, 
the  extension  is  to  be  continued,  only  inclining  the  thumb  a  little 
inwards  toward  the  palm  of  the  hand.  If  these  means  fail  after  having 
been  continued  a  considerable  length  of  time,  he  advises  that  a  weight 
shall  be  suspended  to  the  thumb,  passing  over  a  pulley.  Finally,  in 
the  event  of  the  failure  of  this  method  also.  Sir  Astley  thought  that 
no  further  attempts  should  be  made,  and  especially  that  no  operation 
for  the  division  of  these  parts  is  justifiable. 

Lizars  and  Pirrie  adopt  the  views  of  Sir  Astley  with  little  or  no 
qualification. 

Fi^.  266. 


Sir  Astley  Cooper's  method  of  reducing  dislocations  of  the  thumb,  with  pulleys. 

Charles  Bell  proposed  flexing  the  joint,  employing  also  at  the  same 
time  pressure ;  and  in  obstinate  cases  he  advised  subcutaneous  section 
of  the  lateral  ligaments  with  a  small  knife,  a  method  which  has  since 
been  practised  successfully  by  Liston,  Reinhardt,  Gibson,  of  Philadel- 
phia, Parker,  of  New  York,  and  others.  Syme  and  Lizars  justify  the 
practice  in  certain  cases.  In  one  case  which  has  come  under  my  notice, 
after  failing  to  effect  reduction  by  the  usual  methods,  I  succeeded 
promptly  after  cutting  one  lateral  ligament;  and  in  a  second  case  I 
only  succeeded  after  cutting  both  lateral  ligaments. 

Roser,  from  his  experiments  upon  the  cadaver,  concludes  that  the 
dislocated  phalanx  must  first  be  bent  forcibly  backwards,  or  into  the 
position  termed  by  some  writers  dorsal  flexion,  so  as  to  throw  the  head 
of  the  phalanx  forwards  upon  the  articulating  surface  of  the  metacarpal 
bone.  Parker,  of  New  York,  in  his  notes  to  the  American  edition  of 
Samuel  Cooper's  work,  recommends  the  same  procedure. 

Vidal  (de  Cassis)  recommends  also  that  the  extension  should  be 
made  first  backwards,  so  as  to  increase  the  displacement  of  the  first 
phalanx  in  this  direction,  and  to  throw  forwards  its  articular  surface 
in  the  direction  of  the  articular  surface  of  the  metacarpal  bone. 

This  method,  namely,  dorsal  flexion  as  the  first  and  most  essential 

•  Wadsworth,  Anier.  Med.  Times,  Feb.  13,  18G4,  p.  77. 


624      OF    FIRST    PHALANGES    OF    THUMB    AND    FINGEES. 

part  of  the  manoeuvre,  seems  to  have  met  with  more  general  approval 
than  any  other,  and  the  following  observations,  made  b_7  the  late 
Eeuben  D.  Mussey,  of  Cincinnati,  illustrate  the  general  practice  among 
American  surgeons  at  this  day. 

"I  tilt  the  dislocated  phalanx  up  until  it  stands  upon  its  articu- 
lating end,  place  both  forefingers  so  as  to  hold  it  in  that  position,  and 
at  the  same  time  press  against  the  distal  extremity  of  the  metacarpal 
bone,  make  firm  pressure  with  the  thumbs  against  the  base  of  the 
dislocated  phalanx,  and  slide  it  into  its  place,  which  can  generally  be 
accomplished  with  ease. 

"  More  than  twenty-five  years  ago,  the  chairman  of  this  committee, 
from  attention  to  the  mechanism  of  the  metacarpo-phalangeal  joint  of 
the  thumb,  convinced  himself  that  the  principal  impediment  to  the  re- 
duction of  the  first  phalanx  from  backward  displacement  is  the  short 
flexor  of  the  thumb,  between  the  two  portions  of  which  (lying  close 
together  where  they  are  fastened  to  the  sesamoid  bones)  the  head  of 
the  metacarpal  bone  has  been  thrust,  the  contracted  part  or  neck  of 
this  bone  lying  firmly  grasped  by  them.  Fifteen  years  ago,  a  case 
occurred  of  this  dislocation  Avhich  he  could  not  reduce  in  the  ordinary 
way.  A  subcutaneous  division  of  one  of  the  heads  of  this  muscle  was 
made  with  an  iris  knife,  and  the  reduction  was  accomplished  with  the 
greatest  ease. 

"Last  year  another  case  occurred,  in  which  we  failed  of  reduction 
by  Dr.  Crosby's  method,  which  we  believe  to  be  the  best,  and  the 
subcutaneous  division  of  both  heads  of  the  muscle  was  made,  and  the 
reduction  instantly  effected.  The  punctures  were  covered  with  collo- 
dion, and  the  thumb  supported  by  a  splint.  As  the  patient  was  in- 
temperate, entire  abstinence  from  liquor  and  the  adoption  of  a  light 
diet  were  enjoined.  Neither  pain  nor  inflammation  followed,  and  a 
month  afterwards  the  joint  had  free  motion.  After  the  intemperate 
and  irregular  habits  were  resumed,  the  joint  in  a  few  weeks  was  found 
anchylosed.  In  these  cases,  the  knife,  in  the  subcutaneous  operation, 
was  carried  down  to  the  metacarpal  bone,  so  far  behind  its  head  as  to 
preclude  the  possibility  of  mistaking  the  lateral  ligaments  for  the 
muscles.  The  ligaments  are  very  short,  and  inserted  close  to  the 
articular  surfaces,  and  are  probably,  one  or  both,  ruptured  in  this  dis- 
location.'" 

Dr.  J.  P.  Batchelder,  of  New  York,  in  a  paper  read  before  the  New 
York  Medical  Association  in  1856,  says:  "The  surgeon  should  take 
the  metacarpal  portion  of  the  dislocated  thumb  between  the  thumb 
and  finger  of  one  hand,  and  flex  or  force  it  as  far  as  may  be  into  the 
palm  of  the  hand,  for  the  purpose  of  relaxing  the  muscles  connected 
with  the  proximal  end  of  the  phalanx,  particularly  the  flexor  brevis 
poUicis.  He  should  then  apply  the  end  of  the  thumb  of  his  hand 
against  the  displaced  extremity  of  the  dislocated  phalanx,  for  the  pur- 
pose of  forcing  it  downwards,  and  at  the  same  time  grasp  the  displaced 
thumb  with  his  other  hand,  and  move  it  forcibly  backwards  and  for- 
wards, as  in  strongly  forced  flexion  and  extension,  the  pressure  against 

•  Mussey,  Trans.  Amer.  Med.  Assoc,  vol.  iii.,  1850,  p.  357. 


FIRST  PHALANX  OF  THE  THUMB  BACKWARDS. 


625 


the  upper  extremity  of  the  first  phalanx  being  kept  up.  In  this  way 
the  dislocated  bone  may  be  made  to  descend,  so  as  to  be  almost  or 
quite  on  a  line  with  the  articulating  surface  of  the  metacarpal  bone, 
when  the  thumb  may  be  forcibly  flexed,  and,  if  it  be  not  reduced,  as 
forcibly  extended,  and  brought  backwards  to  a  right  angle  with  the 
metacarpal  bone,  when,  if  the  downward  pressure,  with  the  thumb 
placed  as  before,  directed  for  that  purpose,  has  been  continued  (which 
thumb,  by  maintaining  its  position,  acts  as  a  fulcrum,  as  well  as  by  its 
pressure),  the  bone  will  slip  into  its  place,  and  the  reduction  be  effected 
in  less  time  than  has  been  spent  in  describing  the  process."^ 

Six  successive  cases  of  treatment  by  this  method  are  mentioned  in 
the  American  Journal  of  Medical  Sciences  for  April,  1858;  one  by 
Eickard,  one  by  Morgan,  two  by  Cutter,  and  two  by  Crosby.  I  have 
also  once  succeeded  by  the  same  method. 

By  those  who  have  regarded  extension  as  an  important  element  in 
the  reduction,  various  instruments  have  been  devised  for  the  purpose 
of  obtaining  a  secure  hold  upon  the  dislocated  member.  Sir  Astley 
Cooper,  as  we  have  already  seen,  recommended  the  sailor's  clove 
hitch  ;^  Lawrie  advises  that  the  thumb  shall  be  thrust  into  the  open 
handle  of  a  large  door  key;^  Charri^re  and  Luer,  of  Paris,  have  each 
invented  forceps,  so  constructed  with  fenestra  and  straps,  as  that  when 
the  blades  are  closed  the  member  is  held  very  firmly  in  its  grasp. 
Eichard  J.  Levis,  of  Philadelphia,  recommends  "a  thin  strip  of  hard 
wood,  about  ten  inches  in  length,  and  one  inch,  or  rather  more,  in  width. 

Fi?.  267. 


Levis's  instrument  for  reduction  of  dislocations  of  fingers  or  the  thumb. 

One  end  of  the  piece  is  perforated  with  six  or  eight  holes.  The  oppo- 
site end  is  partly  cut  away,  forming  a  projecting  pin,  and  leaving  a 
shoulder  on  each  side  of  it.  Towards  this  end  of  the  strip,  a  sort  of 
handle  shape  is  given  to  it,  so  as  to  insure  a  secure  grasp  to  the  ope- 
rator. Two  pieces  of  strong  tape  or  other  material,  about  one  yard  in 
length,  are  prepared.  One  of  these  is  passed  through  the  holes  at  the 
end  of  the  strip,  leaving  a  loop  on  one  side.  The  other  tape  is  passed 
through  another  pair  of  holes,  according  as  it  may  be  a  thumb  or  a  finger 
to  which  it  is  to  be  applied,  or  varied  to  suit  the  length  of  the  finger, 
leaving  a  similar  loop.  If  a  dislocated  thumb  is  to  be  acted  on,  the 
second  tape  should  be  passed  through  the  holes  nearest  the  first.  The 
ends  of  each  separate  tape  are  then  tied  together. 

1  Batchelder,  New  York  Jourii.  Med.,  Mav,  ISofi,  p.  o40. 

2  Op.  cit.,  p.  561  ;  also  Bost.  3Icd.  aud  Surg.  Journ.,  Oct.  1,  18o7. 
'  Lawrie,  Am.  Journ,  Med.  Sci.,  vol.  xxii.  p.  239. 


626      OP    FIRST    PHALANGES    OP    THUMB    AND    FINGERS. 

"  To  apply  this  apparatus,  the  finger  is  passed  through  the  loops. 
The  loop  nearest  the  first  joint  is  then  tightened  by  drawing  on  the 

Fis;.  268. 


Levis's  instrument  applied  to  the  first  finger. 

tape,  which  is  then  brought  along  the  strip  to  the  opposite  end,  across 
one  of  the  shoulders,  and  secured  by  winding  it  firmly  around  the 
projecting  pin.  The  other  tape  is  tightened  in  a  like  manner,  cross- 
ing the  other  shoulder,  and  winding  around  the  pin  in  an  opposite 
direction,  when,  for  security,  the  ends  of  the  tapes  are  finally  tied 
together,"^ 

This  apparatus  enables  the  operator  to  apply  both  extension  and 
flexion  or  leverage  in  any  direction.  The  proximal  end  of  the  pha- 
lanx may  be  lifted,  or  even  rotated  so  as  to  allow  one  side  of  the  bone 
to  approach  the  socket  before  the  other. 

Malgaigne  describes  an  apparatus  invented  by  KirchofT,  which  is 
very  similar  to,  yet  not  quite  so  complete  as  this  of  Levis. 

In  the  April  number  of  the  Buffalo  Medical  Journal,  for  1847,  I 
have  described  an  instrument,  or  rather  a  toy,  in  my  possession,  which 
I  suggested  might  be  useful  for  the  purpose  of  making  extension 
upon  dislocated  fingers;  and  which,  as  will  be  seen  by  a  reference  to 
one  of  the  cases  already  reported  in  this  chapter,  I  have  since  applied 
successfully.  It  is  made  by  the  Indians,  and  may  always  be  obtained 
during  the  watering  season,  at  the  Indian  toy-shops  at  Niagara  Falls. 
The  Indians  call  it  a  "  puzzle,"  and  know  no  other  use  for  it  than  to 

Fi-.  2G9. 


Indian  "puzzle,"  employed  for  the  reduction  of  dislocations  in  small  joints. 

fasten  it  upon  the  thumb  or  finger  of  some  victim,  and  then  pull  him 
about  until  he  begs  to  be  released. 

The  •'  puzzle"  is  an  elongated  cone  of  about  sixteen  or  eighteen 
inches  in  length,  made  of  ash  splittings,  and  braided  ;  the  open  end  of 
the  cone  being  about  three-fourths  of  an  inch  in  diameter,  and  the 
opposite  end  terminating  in  a  braided  cord.  When  applied  to  the 
finger,  it  is  slipped  on  lightly,  forming  a  cap  to  the  extremity,  and  to 
half  the  length  of  the  finger,  but  on  traction  being  made  from  the 

'  Levis,  Amer.  Journ.  Med.  Sci.,  Jan.  1857,  p.  62. 


FIRST  PHALANX  OF  THE  THUMB  FORWARDS.    627 

opposite  end,  it  fastens  itself  to  the  limb  with  a  most  uncompromisino- 
grasp.  If  constructed  of  appropriate  size  and  of  suitable  materials, 
it  becomes  the  more  securely  fastened  in  proportion  as  the  extension 
is  increased;  yet,  applying  itself  equally  to  all  the  surfaces,  it  inflicts 
the  least  possible  pain  and  injury  upon  the  limb.  When  we  wish  to 
remove  it,  we  have  only  to  cease  pulling,  and  it  drops  off  spontane- 
ously. 

Dr.  Holmes  says  that  the  same  instrument  is  made  by  the  Indians 
of  Maine,  and  that  several  years  ago  Dr.  Davis,  of  Portland,  brought 
one  to  Boston,  and  showed  it  to  the  Society  for  Medical  Improvement, 
suggesting  that  it  might  be  used  in  the  same  manner  which  I  have 
recommended.' 

Finally,  in  some  compound  dislocations  it  would  be  better  not  to 
attempt  the  reduction  of  the  dislocation  until  resection  has  been  prac- 
tised. Samuel  Cooper  relates  a  case  in  which  the  reduction  was  fol- 
lowed by  inflammation  and  death  within  a  week  after  the  accident, 
and  Norris,  of  Philadelphia,  mentions  an  instance  which  came  under 
his  observation,  where  violent  inflammation  and  tetanus  followed  the 
reduction.^  Eoux,  Evans,  Wardrop,  Gooch,  Sir  Astley  Cooper,  and 
many  other  surgeons,  have  practised  resection  successfully  in  these 
accidents,  and  have  added  their  testimony  in  favor  of  this  mode  of 
procedure. 

§  2.  Dislocations  of  the  First  Phalanx  op  the  Thumb  Forwards. 

Up  to  the  present  moment,  I  have  met  with  but  two  examples  of 
this  dislocation,  while,  as  has  been  already  stated,  the  backward  dis- 
location has  been  seen  by  me  nine  times. 

Horace  Kneeland,  of  Kochester,  N.  Y.,  aet.  24,  dislocated  the  first 
phalanx  of  the  right  thumb  forwards,  by  striking  a  man  with  his 
clenched  fist;  the  ibrce  of  the  blow  being  received  upon  the  back  of 
the  second  joint  of  the  thumb.  The  dislocation  had  existed  three 
days  when  he  called  upon  me,  and  in  the  meanwhile  several  attempts 
had  been  made  to  reduce  the  bone  by  simple  extension.  The  first 
phalanx  was  in  front  of  the  metacarpal  bone,  and  in  the  same  plane ; 
but  the  last  phalanx  was  slightly  inclined  backwards.  The  hand  was 
already  swollen  and  quite  painful. 

Seizing  the  dislocated  thumb  in  the  palm  of  my  right  hand,  with 
my  fingers  resting  upon  the  back  of  the  patient's  hand,  I  forced  the 
two  phalanges  into  flexion  by  firm  and  steady  pressure  continued  for 
a  few  seconds,  when  suddenly  the  bones  resumed  their  places,  and  all 
deformity  disappeared. 

Intense  inflammation  resulted,  followed,  after  a  few  days,  by  suppu- 
ration under  the  palmar  fascia ;  and  in  the  end  the  thumb  was  almost 
completely  anchylosed.^ 

On  the  24th  of  April,  1855,  J.  M.  Booth,  of  Buffalo,  set.  19,  called 
at  my  office,  having  a  dislocation  forwards  of  the  first  phalanx,  occa- 

'  Trans.  Am.  Med.  Assoc,  vol.  i.  p.  267. 

2  Norris,  Amer.  Journ.  Med.  Sci.,  vol.  xxxi.  p.  16. 

3  Trans.  N.  Y.  State  Med.  Soc.,  1855,  p.  73. 


628      OF    FIEST    PHALANGES    OF    THUMB    AND    FINGERS. 

sioned  about  half  an  hour  before,  by  being  thrown  from  a  horse.  The 
last  two  phalanges  were  neither  flexed  nor  extended,  but  straight,  and 
parallel  with  the  metacarpal  bone. 

By  the  same  manoeuvre  adopted  in  the  preceding  case,  but  with 
only  very  moderate  force,  the  dislocation  was  promptly  reduced. 

The  usual  causes  of  this  accident  are  falls  or  blows  upon  the  thumb 
while  it  is  flexed ;  and  the  symptoms  which  characterize  it  are,  in 
general,  such  as  we  have  seen  in  the  two  examples  which  have  just 
been  given.  The  metacarpal  bone  projects  posteriorly,  and  the  first 
phalanx  produces  a  corresponding  projection  toward  the  palm ;  the 
two  phalanges  are  extended  upon  each  other,  and  parallel  with  the 
metacarpal  bones.  Nelaton  saw  a  case  in  which  the  first  phalanx  was 
flexed  about  45° ;  and  in  several  examples  it  has  been  observed  to 
be  slightly  rotated  inwards. 

In  the  few  examples  of  this  accident  which  have  been  reported,  the 
reduction  was  easily  accomplished ;  or,  at  least,  we  may  say  that  the 
difficulties  in  the  way  of  reduction  were  not  so  great  as  they  are 
usually  found  to  be  in  dislocations  backwards.  Malgaigne  has  been 
able  to  collect  but  four  undoubted  examples,  all  of  which  were  re- 
duced ;  Lenoir  was  able  to  effect  the  reduction  by  moderate  measures, 
after  the  bone  had  been  dislocated  thirty-eight  days.  Ward  succeeded 
by  simple  extension.^ 

Lombard,  after  the  trial  of  other  plans,  finally  succeeded  by  revers- 
ing the  phalanx.  Employing,  as  we  have  before  termed  it,  "dorsal 
flexion,"  with  extension  and  lateral  motion ;  but  in  all,  or  nearly  all 
the  other  examples,  the  reduction  has  been  effected  by  flexing  the 
thumb  forcibly  toward  the  palm  ;  the  reverse  of  the  method  which 
we  have  seen  preferred,  especially  by  American  surgeons,  in  disloca- 
tions backwards.  My  own  experience  alsa  authorizes  me  to  recom- 
mend this  plan. 

§  3.  Dislocations  of  the  First  Phalanx  of  the  Fingers. 

The  index  and  little  fingers,  owing  to  their  exposed  situations,  are 
most  liable  to  these  dislocations.  I  have  met  with  three  examples  of 
traumatic  dislocations  of  these  joints,  one  of  which  was  a  forward  and 
two  were  backward  luxations,  and  all  had  occurred  in  the  index 
finger. 

James  Nesbitt,  of  Buffalo,  ast.  11,  dislocated  the  index  finger  of  the 
right  hand,  backwards,  by  a  fall  down  a  flight  of  stairs.  On  the  same 
day,  Feb.  11,  1851,  he  called  upon  me,  and  I  found  the  finger  neither 
flexed  nor  extended,  but  straight  and  immovable.  The  projections 
occasioned  by  the  ends  of  the  two  bones  were  very  marked,  and  such 
as  to  render  an  error  in  the  diagnosis  impossible.  Reduction  was 
accomplished  with  great  ease,  by  reversing  the  finger  and  employing 
moderate  extension,  while  at  the  same  time  the  proximal  extremity  of 
the  first  phalanx  was  pushed  toward  the  distal  end  of  the  metacarpal 

'  Ward,  New  York  Med.  Times,  Sept.  8,  1860. 


PHALAXGES    OF    THE    THUMB    AND    FINGERS.  629 

bone.     In  short,  the  process  was  the  same  as  that  which  we  have 
recommended  in  dislocations  of  the  thumb  backwards. 

Fig.  270. 


Backward  dislocation  of  first  phalanx.     Reduction  by  extension. 

In  the  second  case,  presented  in  a  woman  35  years  of  age,  at 
Charity  Hospital,  April  16,  1868,  the  dislocation  was  caused  by  her 
husband  having  pulled  the  finger  violently  backwards.  The  meta- 
carpal bone  was  thrust  through  the  skin  on  the  palm  of  the  hand. 
Four  weeks  had  now  elapsed,  and  the  wound  had  healed,  a  few  days 
before  the  house  surgeon  had  placed  her  under  the  influence  of  ether 
and  had  attempted  reduction,  but  had  failed,  and  she  refused  to  allow 
me  to  repeat  the  attempt. 

In  the  example  of  dislocation  forwards,  occasioned  by  a  blow  from 
a  hard  ball,  received  upon  the  end  of  the  finger,  the  first  phalanx  was 
in  a  position  of  extreme  extension,  and  the  second  moderately  flexed. 
Reduction  was  effected  with  great  ease  by  extension  in  a  straight  line. 
But  if  the  surgeon  were  to  experience  difficulty  in  the  reduction,  it 
would  no  doubt  be  advisable  to  resort  to  the  method  of  extreme 
flexion. 

In  one  instance,  I  have  seen  nearly  all  the  fingers  of  the  left  hand, 
and  the  thumb  of  the  right,  dislocated  backwards  by  the  contraction 
of  the  cicatrix  after  a  severe  burn. 


CHAPTER   XV. 

DISLOCATIONS  OF  THE  SECOND  AND  THIRD  PHALANGES  OF 
THE  THUMB  AND  FINGERS. 

Notwithstanding  slight  differences  in  the  form  of  the  articulations 
between  the  thumb  and  fingers,  and  in  the  size  and  situation  of  the 
bones  which  compose  the  phalanges  of  the  fingers,  we  are  disposed, 
contrary  to  the  practice  of  some  other  writers  upon  this  subject,  to 
consider  all  the  dislocations  to  which  these  several  joints  are  liable, 
under  one  section.  Nor,  indeed,  after  the  attention  which  we  have 
given  to  the  dislocations  at  the  metacarpo-phalangeal  articulations,  do 
we  find  much  to  add  in  relation  to  these  accidents;  since  in  almost 
every  point  of  view  in  which  they  may  be  considered,  they  have  so 
much  in  common. 


630  PHALANGES    OF    THE    THUMB    AND    FINGERS. 

The  last  phalanx  of  the  thumb  is,  of  all  the  phalanges,  most  liable 
to  dislocation,  and  this  generally  takes  place  backwards.  Very 
frequently,  also,  it  is  accompanied  with  such  a  laceration  as  to  render 
it  compound.  The  dislocated  phalanx  is  usually  reversed  in  the 
backward  dislocation,  and  straight,  or  nearly  so,  in  the  forward  dislo- 
cation. 

In  most  cases  reduction  may  be  accomplished  easily  by  forced  dorsal 
flexion  in  the  case  of  the  backward  luxation,  and  by  forced  palmar 
flexion  in  the  case  of  the  forward  dislocation. 

In  the  winter  of  1848,  a  young  man  was  brought  into  my  clinic, 
who  had  met  with  a  forward  subluxation  of  this  phalanx  about  one 
month  before.  He  had  fallen  upon  the  end  of  his  thumb,  and  as  the 
accident  was  followed  by  a  good  deal  of  inflammation  and  swelling, 
he  did  not  notice  the  displacement  until  some  time  afterwards.  The 
proximal  end  of  the  last  phalanx  projected  two  or  three  lines  toward 
the  palm ;  the  finger  was  straight,  and  this  joint  anchylosed.  I  did 
not  think  the  chance  of  restoring  and  maintaining  the  bone  in  position 
sufficient  to  warrant  any  interference,  and  he  was  dismissed  with  an 
assurance  that  after  a  few  months  it  would  occasion  him  no  great 
inconvenience. 

On  the  2d  of  March,  1851,  Thomas  Burton,  aged  about  twenty-two 
years,  by  a  fall  dislocated  the  second  phalanx  of  the  middle  finger  of 
the  right  hand,  backwards.  The  force  of  the  concussion  was  received 
upon  the  extremity  of  the  finger.  Nine  hours  after  the  accident  I 
found  the  bones  unreduced ;  the  finger  nearly  straight,  or  with  only 
slight  flexion  of  the  second  phalanx  upon  the  first;  the  third  phalanx 
forcibly  straightened  upon  the  second ;  all  the  joints  rigid  ;  finger  very 
painful  and  somewhat  swollen. 

By  moderate  extension  alone,  applied  for  a  few  seconds,  the  reduc- 
tion was  accomplished. 

Fig.  371. 


Dislocation  of  the  second  phalanx  backwards. 

James  Cooper,  set.  23,  came  to  me  on  Sunday  morning,  the  14th  of 
Dec.  1851,  to  obtain  counsel  in  relation  to  his  finger  which  had  been 
dislocated  the  day  before,  but  which  he  had  himself  reduced  by  simple 
extension  made  in  a  straight  line.  His  own  account  of  it  was,  that  he 
fell  upon  a  slippery  side-walk,  striking  upon  the  end  of  his  ring  finger 
in  such  a  way  that  it  seemed  to  double  under  him.  On  examination, 
he  found  the  second  bone  dislocated  inwards,  or  to  the  ulnar  side,  com- 
pletely, the  end  of  the  first  phalanx  forming  a  broad  projection  upon 
the  opposite  side;  the  last  two  phalanges  fell  over  toward  the  middle 
finger,  but  they  were  neither  flexed  nor  extended.-    Seizing  upon  the 


PHALANGES    OF    THE    THUMB    AXD    FINGERS.  631 

end  of  the  finger  with  his  right  hand  and  pulling  forcibly,  he  promptly 
reduced  the  dislocation  himself. 

The  bones  were  now  completely  in  place,  but  the  joints  were  swollen, 
tender,  and  quite  stiff. 

In  Sept.  1851,  by  the  politeness  of  Dr.  Briggs,  the  attending  sur- 
geon, I  was  permitted  to  see,  in  the  hospital,  of  the  New  York  State 
Prison,  at  Auburn,  a  forward  dislocation  of  the  second  phalanx  of  the 

Fior.  273. 


Dislocation  of  the  secoud  phalanx  forwards. 

little  finger  of  the  left  hand,  unreduced.  This  man  was  at  the  date  of 
my  examination  forty-one  years  old,  and  the  dislocation  had  existed 
eighteen  years;  having  been  occasioned  by  a  fall.  A  surgeon  in 
Greene  Co.,  N.  Y.,  had  attempted  to  reduce  it  soon  after  the  dislocation 
occurred,  but  had  failed.  The  joint  was  nearly  anchylosed,  yet  the 
finger  was  quite  as  useful  for  all  ordinary  purposes  as  before. 

Dislocation  of  the  last  phalanx  is  frequently  occasioned  in  the 
game  of  base  ball,  by  the  ball  being  received  upon  the  extremity  of 
the  finger. 

A  young  man  who  was  studying  medicine,  and  a  private  pupil  of 
mine,  in  attempting  to  catch  a  very  hard  ball,  received  it  upon  the 
extremity  of  the  middle  finger  of  the  left  hand,  dislocating  the  last 
phalanx  forwards.  Twenty  minutes  after  the  accident,  I  found  the 
distal  extremity  of  the  second  phalanx  projecting  backwards  through 
the  skin,  the  tendon  of  the  extensor  muscle  being  torn  completely  off 
from  its  point  of  attachment  to  the  last  phalanx.  The  last  phalanx 
was  in  a  position  of  slight  dorsal  flexion,  or  extreme  extension. 

Seizing  upon  the  extremity  of  the  finger,  I  attempted  to  reduce  the 
dislocation  by  direct  traction,  aided  by  pressure  upon  the  exposed  end 
of  the  second  phalanx,  but  I  was  unable  to  succeed  until  I  brought 
the  last  phalanx  into  a  ])osition  of  palmar  flexion. 

A  slight  disposition  to  reluxation  was  manifested,  and  a  gutta- 
percha splint  was  therefore  applied ;  and,  to  prevent  inflammation, 
the  young  man  was  directed  to  keep  it  moistened  with  cool  water 
lotions.  Only  a  moderate  amount  of  inflammation  followed,  and  in  a 
few  weeks  the  cure  was  complete. 

Such  accidents,  attended  with  laceration  of  the  integuments,  fre- 
quently demand  amputation,  or  at  least  resection  of  the  projecting 
bone,  but  we  think  Mr.  Miller  is  scarcely  right  when  he  says  that 
compound  dislocations  of  the  fingers  almost  always  are  of  such  severity 
as  to  demand  amputation.  I  have  myself  met  with  three  other  cases 
which  were  reduced,  and  did  well. 

In  one  case  of  simple  dislocation  of  the  last  phalanx  of  the  thumb 


632  DISLOCATIONS    OF    THE    THIGH. 

backwards  I  have  been  obliged  to  resort  to  section  of  the  lateral  liga- 
ments before  accomplishing  the  reduction.  This  was  in  the  person  of 
a  woman  admitted  to  Bellevue  Hospital  in  February,  1864:.  The  acci- 
dent had  happened  seven  days  before,  by  falling  and  striking  upon 
the  end  of  the  thumb.  The  position  of  the  last  phalanx  was  extended, 
that  is,  in  a  line  with  the  axis  of  the  first  phalanx.  She  said,  how- 
ever, that  it  was  at  first  "  bent  straight  back,"  but  that  a  man  took  hold 
of  it  and  pulled  it  out.  Having  placed  her  under  the  influence  of 
ether,  I  attempted  reduction  by  forced  backward  flexion,  but  failed.  I 
then  cut  the  lateral  ligaments  by  subcutaneous  incision,  and  the  re- 
duction was  accomplished  with  great  ease. 


CHAPTER    XVI. 

DISLOCATIONS  OF  THE  THIGH  (COXO-FEMORAL). 

The  femur  is  especially  liable  to  dislocation  in  four  directions, 
namely,  upwards  and  backwards  upon  the  dorsum  ilii,  upwards  and 
backwards  into  the  ischiatic  notch,  downwards  and  forwards  into  the 
foramen  thyroideum,  and  upwards  and  forwards  upon  the  pubes. 

Dislocations  are  occasionally  met  with  which  cannot  be  arranged 
properly  under  either  of  these  divisions ;  indeed,  it  is  scarcely  neces- 
sary to  say  that  the  head  of  the  bone  may  be  thrown  in  almost  every 
direction  from  its  socket,  upwards,  downwards,  inwards,  and  outwards, 
or  in  either  of  the  diagonals  between  these  lines;  and  that  while  in  a 
vast  majority  of  cases  it  willassume  one  of  the  positions  first  named, 
it  may  in  a  few  exceptional  examples  fall  short  of,  or  much  exceed,  the 
limits  assigned  in  this  division.  Thus,  we  shall  have  occasion  here- 
after to  mention  examples  of  dislocation  directly  upwards,  in  which 
the  head  of  the  bone  will  be  found  resting  upon  the  fossa  between  the 
upper  margin  of  the  acetabulum  and  the  anterior  inferior  spinous  pro- 
cess of  the  ilium,  or  still  higher  between  the  anterior  superior  and  the 
anterior  inferior  spinous  processes,  or  a  little  to  the  one  side  or  to  the 
other  of  these  points.  Examples  will  be  shown  of  dislocations  directly 
downwards,  in  which  the  head  of  the  femur  will  rest  upon  the  notch 
between  the  lower  margin  of  the  acetabulum  and  the  tuber  ischii,  or 
still  lower,  and  actually  below  the  tuberosity,  or  downwards  and  back- 
wards below  the  spine  of  the  ischium,  into  the  lower  or  lesser  sacro- 
sciatic  notch.  The  head  may  be  thrust  across  the  foramen  thyroideum, 
and  be  only  arrested  in  the  perineum  upon  the  ramus,  or  even  beyond 
the  ramus  of  the  ischium  and  pubes ;  it  may  lodge  upon  the  anterior 
surface  of  the  body  of  the  pubes,  as  well  as  upon  its  superior  edge; 
and  finally,  it  may  rest  against  the  posterior  margin  of  the  acetabulum 
instead  of  rising  upon  the  dorsum,  or  it  may  only  mount  upon  its 
margin,  in  either  of  the  directions  named. 

In  regard  to  frequency,  the  four  principal  dislocations  occur  in  the 
order  in  which  we  have  mentioned  them ;  thus,  of  10-i  dislocations  of 


DISLOCATIOXS    OF    THE    THIGH.  633 

the  hip  which  I  have  taken  the  pains  to  collate,  excluding  the  anoma- 
lous or  extraordinary  dislocations,  and  which  my  intelligent  pupil,  Mr. 
Frank  Hodge,  has  carefully  analyzed,  55  were  upon  the  dorsum  ilii, 
28  into  the  great  ischiatic  notch,  18  upon  the  foramen  thyroideum,  and 
8  upon  the  pubes.  Chelius  and  Samuel  Cooper  have,  however,  re- 
versed the  order  of  the  last  two  varieties,  arranging  dislocations  upon 
the  pubes,  in  the  order  of  frequency,  before  dislocations  into  the  fora- 
men thyroideum, 

Coxo-femoral  dislocations  may  occur  at  any  period  of  life ;  a  case 
of  thyroid  dislocation  is  reported  in  the  Lancet  for  May  16,  1863, 
which  occurred  in  a  child  six  months  old.  One  example  is  men- 
tioned in  the  Gazdte  Midicale,  of  a  recent  dislocation  upon  the  dorsum 
ilii,  in  a  child  eighteen  months  old.'  Dr.  N.  Fanning,  of  Catskill,  N. 
Y,,  informs  me,  in  a  letter  dated  June  25th,  1867,  that  he  has  reduced 
a  dislocation  upon  the  dorsum  ilii,  on  the  tenth  day,  in  a  little  girl 
eighteen  months  old.  Mr.  Kirby  has  reported,  in  the  Dublin  Medical 
Press  for  October  26,  18-42,  a  case  of  recent  dislocation  in  the  same 
direction,  in  a  child  of  three  years,^  and  Dr.  Buchanan  has  seen  another, 
at  the  same  age,  in  a  little  girl ;  the  dislocation  being  into  the  ischiatic 
notch.^  Mr.  Image  communicated  to  the  Suffolk  branch  of  the  Pro- 
vincial Medical  and  Surgical  Association  the  case  of  a  boy,  three  and 
a  half  years  old,  with  a  dislocation  upon  the  dorsum  ilii.  It  had  ex- 
isted twelve  da3''s  when  he  was  admitted  to  the  Suffolk  Hospital  in 
May,  1847.  Mr.  Image,  in  reporting  this  case  to  the  Society,  remarked 
that  he  had  been  induced  to  lay  it  before  them  "  in  consequence  of  a 
charge  having  been  urged  against  a  neighboring  surgeon,  of  pretend- 
ing to  reduce  a  dislocation  of  the  femur  on  the  dorsum  ilii,  in  a  child 
only  four  years  old,  that  child  being  a  pauper,  and  chargeable  to  the 
parish.  It  was  agreed  and  proved  by  authorities  that  no  such  case 
was  recorded,  and  therefore  had  not  occurred,  and  that  seven  years 
old  was  the  earliest  period  at  which  this  accident  had  taken  place."* 

J.  M.  Litten,  of  Austin,  Texas,  reports  a  case  of  dislocation  upon 
the  dorsum  ilii  in  a  girl  four  years  old,  which  he  reduced  by  manipu- 
lation.^ In  the  Jan.  No.  for  1847  of  the  Americaji  Journal  of  Medical 
Sciences  is  reported  a  forward  dislocation  in  a  boy  aged  five  years,  and 
a  dislocation  into  the  ischiatic  notch  in  a  girl  of  the  same  age. 

Dr.  J.  C.  Warren,  of  Boston,  met  with  an  incomplete  dislocation 
toward  the  foramen  thyroideum  in  a  child  six  years  old,  which,  having 
been  displaced  eight  or  ten  weeks,  he  was  unable  to  reduce.''  Sir 
Astley  Cooper  mentions  a  case  in  a  girl  seven  years  old.'^  I  have 
myself  met  with  two  dislocations  upon  the  dorsum  ilii,  which  occurred 
at  ten  years,  and  one  into  the  foramen  thyroideum.^     Norris  reports  a 

'  New  York  Journ.  Med.,  Nov.  1850,  p.  416. 

2  Amer.  Journ.  Med.  Sci.,  vol.  xxxi.  p.  207,  Jan.  1843. 

3  London  Med.-Chir.  Rev.,  Dec.  1828,  p.  251. 

<  New  York  Journ.  Med.,  Sept.  1848,  p.  381.        =  Ujia.,  March,  1852,  p.  259. 
6  Boston  Med.  and  Surg.  Journ.,  vol.  xxiv.  p.  220. 
'  A.  Cooper,  on  Disloc,  Amer.  ed.,  p.  83,  Case  27. 

8  Buffalo  Med.  Journ.,  vol.  viii.  p.  6.     Trans.  New  York  State  Med.  Soc,  1855. 
My  Report  on  Disloc. 
41 


634  DISLOCATIONS    OF    THE    THIGH. 

case  at  eleven  years/  and  Gibson  at  twelve."  On  the  otber  hand, 
Gautheir  has  seen  a  dislocation  of  the  hip  in  a  woman  eighty-six  years 
of  age.^  The  large  majority,  however,  occur  between  the  fifteenth  and 
forty-fifth  years  of  life.  From  an  analysis  of  eighty-four  cases,  we 
have  obtained  the  following  results : — 


Under  15  years 
15  to  30        " 
30  to  45        " 
45  to  60        " 
66  to  85        " 


15  cases. 
33     " 
29     " 


1  case. 


The  youngest  being  eighteen  months  old,  the  oldest  sixty-two  years, 
and  the  average  thirty-four  years. 

They  are  much  more  frequent  in  men  than  in  women;  owing,  pro- 
bably, to  the  greater  exposure  of  the  former  to  the  accidents  from 
which  these  dislocations  usually  result,  and  possibly,  also,  in  some 
measure,  to  certain  peculiarities  in  the  form  and  structure  of  the  neck 
of  the  femur  in  the  male.  Of  one  hundred  and  fifteen  cases  collected 
by  me,  one  hundred  and  four  were  in  males  and  eleven  in  females. 
Dr.  J.  K.  Eodgers,  of  New  York,  mentioned,  however,  at  a  meeting  of 
the  New  York  Kappa  Lambda  Society,  that  he  had  seen  and  reduced 
four  dislocations  of  the  femur  upon  the  dorsum  ilii  in  females,  and 
that  a  fifth  case  had  recently  come  to  his  knowledge  in  the  New  York 
City  Hospital." 

Gibson  mentions  an  example  of  dislocation  of  both  thighs  at  the 
same  moment.* 

§  1.  Dislocations  Upwards  and  Backwards  on  the  Dorsum  Ilii. 

Syn.—^''  Upwards  on  the  dorsum  ilii;"  Sir  A.  Cooper,  Miller,  Pirrie.  "  Upwards 
and  outward  ;"  Boyer,  Dupuytren.  "  Upwards  and  backwards  upon  the  back  of 
the  hip  bone;"  Chelius.     "Iliac;"  Gerdy,  Vidal  (de  Cassis),  Malgaigne. 

Causes. — Generally  they  are  occasioned  by  some  violence  which 
forces  the  thigh  into  a  state  of  extreme  adduction,  or  of  adduction 
united  with  rotation  inwards ;  and  especially  when  at  the  same  mo- 
ment the  head  of  the  femur  is  driven  upwards  and  backwards.  Thus, 
a  dislocation  upon  the  dorsum  may  result  from  a  fall  from  a  height, 
when  the  force  of  the  concussion  is  received  upon  the  outside  of  the 
knee ;  the  thigh  being  thus  converted  into  a  lever  of  the  first  kind, 
whose  long  arm  is  outside  of  the  margin  of  the  acetabulum ;  or  the 
dislocation  may  be  occasioned  by  a  fall  upon  the  foot  or  knee,  while 
the  limb  is  adducted,  by  which  the  head  of  the  femur  will  be  at  the 
same  moment  driven  upwards  and  outwards  from  its  socket.  The 
accident  is  equally  liable  to  result  from  the  fall  of  a  heavy  weight, 
such  as  a  mass  of  earth,  upon  the  back  of  the  pelvis  when  the  body 
is  much  bent  forwards. 

The  following  case  presents  an  extraordinary  example  of  this  form 

'  Amer.  Journ.  Med.  Sci.,  Feb.  1839,  p.  296.         «  Gibson's  Surg.,  vol.  i.  p.  389. 
^  Gauthier,  Malgaigne,  op.  cit.,  p.  805. 

4  J.  K.  Rodgers,  New  York  Journ.  Med.,  July,  1839,  vol.  i.,  first  ser.,  p.  220. 

5  Gibson's  Surg.,  vol.  i.  p.  385.     Sixth  ed. 


UPWARDS    AND    BACKWARDS    ON    THE    DORSUM    ILII.      635 


Fiff.  273. 


of  dislocation,  produced  by  a  force  acting  upon  the  tbigh  as  a  lever  of 
the  first  kind  : — 

B.,  of  Kochester,  N.  Y.,  £et.  10,  fell,  in  Feb.  1841,  from  the  top  of  the 
high  bank  just  below  the  Genesee  Falls,  at  Rochester,  a  distance  of 
about  one  hundred  feet.  Before  he  reached  the  bottom  of  the  preci- 
pice, he  struck  upon  an  oblique  plane  of  ice,  from  which  he  slid  gradu- 
ally down  upon  the  surface  of  the  river,  which  was  then  completely 
frozen  over.  He  did  not  lose  his  consciousness  in  the  descent,  nor 
after  his  arrest  upon  the  river,  but  began  immediately  to  call  for  as- 
sistance. He  remembers  very  well  that  when  he  struck  the  glacier,  the 
concussion  was  received  upon  the  right  side  of  the  right  knee,  and  a 
mark  of  contusion  at  this  point  confirmed  his  statement.  Dr.  EUwood, 
of  Rochester,  assisted  by  myself,  reduced  the  dislocation  within  one 
hour  after  its  occurrence.  We  employed  pulleys,  but  the  reduction 
was  accomplished  easily  in  about  two  minutes,  and  without  the  appli- 
cation of  much  force;  the  bone  resuming  its  place  with  an  audible 
snap.     His  recovery  was  rapid  and  complete.' 

Pathological  Anatomy. — The  capsule  is  lacerated  more  or  less  ex- 
tensively, but  especially  in  its  posterior  half;  the  round  ligament  is 
ruptured;  some  of  the  small  external  rotator  muscles  are  generally 
stretched  or  torn  completely  asunder,  the  glutteus  maximus,  medius, 
and  minimus  are  pushed  upwards  and 
folded  upon  each  other,  the  head  of  the 
femur  resting  upon  or  within  the  fibres 
of  the  deeper  muscles;  the  triceps  ad- 
ductor is  put  upon  the  stretch. 

Surgeons  have  not  been  agreed  as  to 
the  cause  of  the  great  difficulty  which 
has  usually  been  experienced  in  the  re- 
duction of  this  and  of  all  other  forms  of 
coxo-femoral  dislocations.  While  some 
have  ascribed  it  alone  to  the  resistance  of 
the  muscles,  others  have  with  equal  con- 
fidence ascribed  the  opposition  to  an  en- 
tanglement of  the  head  and  neck  of  the 
bone  in  the  rent  capsule,  or  in  the  liga- 
ment; and  still  others  believe  that  the 
impediment  ought  to  be  looked  for  some- 
times in  the  muscles  and  sometimes  in  the 
capsule,  or  in  both  at  the  same  moment. 

Sir  Astley  Cooper  thought  that  the 
capsular  ligament  was  generally  too  much 
torn  to  ofier  any  impediment  to  reduction, 
and  he  refers  to  some  dissections  in  con- 
firmation of  this  opinion.  Nathan  Smith  affirmed  that  the  chief  obstacle 
to  reduction  by  extension  was  to  be  found  in  the  resistance  offered  by 
the  gluteii  muscles,  which,  although  at  first  relaxed,  would  soon  become 
tense  under  the  stimulus  of  the  extension,  and  which,  in  order  that 


Dislocation  upou  tlie  dorsum  ilii. 


'  Trans.  New  York  State  Med.  Soc.,  1855,  p.  7G.     My  report  on  Dislocations. 


636  DISLOCATIONS    OF    THE    THIGH. 

the  bone  might  resume  its  position,  must  actually  be  stretched  con- 
siderably beyond  their  normal  length.^  W.  W.  Reid  declares  that 
the  sole  resistance  is  at  first  in  the  abductors  and  rotators,  but  that 
finally  the  psoas  magnus,  iliacus  internus,  and  triceps  adductor  become 
tense\vhere  the  pulleys  are  employed.^  Chassaignac  recognizes  no 
other  impediment  to  reduction  than  the  contractions  of  the  muscles.^ 

Dr.  Fenner,  of  New  Orleans,  gives  the  particulars  of  a  dissection  of 
the  hip  of  a  man  admitted  into  the  Charity  Hospital,  who  died  from 
injuries  received  by  the  bursting  of  a  steamboat  boiler.  His  condi- 
tion being  considered  hopeless,  no  attempt  was  made  to  reduce  the 
dislocation.  The  limb  was  shortened  one  inch  and  a  half,  and  the  toes 
turned  inwards.  Extensive  ecchymosis  existed.  On  raising  the  glu- 
teus maximus  and  medius,  the  naked  head  of  the  femur  was  found 
lying  on  the  dorsum  ilii  with  the  ligamentum  teres  hanging  to  it,  but 
partially  torn  ofi^'.  Portions  of  the  obturator  externus  pyriformis,  and 
gemelli,  were  ruptured  and  lacerated.  The  capsule  was  torn  through 
one-half  of  its  extent. 

Dr.  Fenner  now  proceeded  to  cut  away  the  muscles,  and  when  all 
the  external  muscles  about  the  joint  had  been  removed  the  thigh  could 
not  be  brought  down ;  the  iliacus  internus  and  psoas  magnus  Avere 
then  severed,  which  permitted  it  to  descend  a  little,  but  the  head  could 
not  be  replaced  ;  the  triceps  adductor  was  then  divided  without  effect. 
The  ilio-femoral  ligament  was  found  tensely  stretched.  All  the  mus- 
cles between  the  pelvis  and  the  thigh  were  then  severed,  and  still  it 
was  impossible  to  reduce  the  dislocation  ;  the  head  of  the  femur  could 
not  be  forced  back  through  the  rent  in  the  capsule  from  which  it  had 
escaped  ;  and  it  was  not  until  the  opening  was  enlarged  from  one-half 
to  three-quarters  of  an  inch,  that  the  reduction  was  accom})lished. 

Dr.  Fenner  infers  that  the  capsule  possesses  sufficient  elasticity  to 
allow  the  small  head  of  the  femur  to  pass  out  through  a  lacerated 
opening,  which  might  at  once  contract,  so  as  to  offer  considerable  re- 
sistance to  its  return,  and  that  occasionally  this  is  the  true  explanation 
of  the  difficulty  in  reduction.^  Dr.  Gunn,  of  Ann  Arbor,  Michigan, 
after  repeated  experiments  made  upon  the  dead  body,  concludes  that 
the  muscles  offer  no  impediment  whatever  to  the  reduction,  and  that 
the  "untorn  portion  of  the  capsular  ligament,  by  binding  down  the 
head  of  the  dislocated  bone,  prevents  its  ready  return  over  the  edge  of 
the  acetabulum  to  its  place  in  the  socket."*  Dr.  Moore,  of  Rochester, 
who  has  often  repeated  the  same  experiments  upon  the  cadaver,  de- 
clares, also,  that  in  attempting  to  reduce  the  femur  by  extension  alone 
he  has  constantly  observed  that  the  untorn  portion  of  the  capsule 
offered  the  main  resistance,  and  that  reduction  could  not  be  accom- 
plished until  this  was  more  completely  broken  up.*^ 

'  Surgical  Memoirs,  by  N.  R.  Smith,  1831. 
•  •=  Buffalo  Med.  Journ.,  1851.     Trans.  N.  Y.  State  Med.  Soc,  1852. 
3  London  Med.  Times  and  Gazette,  Dec.  1865,  p.  661. 

^  New  York  Journ.  Med.,  Sept.  1848,  p.  208  ;  from  New  Orleans  Med.  and  Surg. 
Journ.,  July,  1848. 
s  Ibid.,  Nov.  1853,  p.  423  et  seq. 
«  Ibid.,  Jan.  1855. 


UPWARDS    AND    BACKWARDS    ON    THE    DORSUM    ILII.      637 


Busch,  of  Bonn,  has  arrived  at  similar  conclusions;'  as  also  Profs. 
Eoser,  Weber,  and  Gelle.  Prof.  Von  Pitba  declares  emphatically  that 
upon  a  knowledge  of  the  ilio-femoral  ligament  is  based  the  correct 
understanding  of  the  various  forms  of  hip-joint  dislocations.^ 

But  probably  the  most  complete  and  conclusive  defence  of  the  views 
entertained  by  the  gentlemen  just  referred  to  has  been  furnished  by 
Dr.  Henry  J.  Bigelow,  the  Pro- 
fessor of  Surgery  in  the  Harvard  ^'S-  ^T-l. 
University.     In  some  respects, 
also,  his   opinions   are    wholly 
original.     The  following   is   a 
brief  summary  of  these  opinions. 

The  ilio-femoral  ligament, 
called  by  Dr.  Bigelow  the  Y 
ligament  (Bertin's  ligament),  the 
internal  obturator  muscle,  and 
that  portion  of  the  capsule  of 
the  joint  which  is  immediately 
subjacent,  are  alone  required  to 
explain,  and  are  chiefly  respon- 
sible for,  the  phenomena  of  the 
four  .regular  dislocations.  The 
regular  dislocations  are  those  in 
which  complete  disruption  of 
the  ilio-femoral  ligament  has 
not  taken  place. 

The  irregular  dislocations  are 
those  in  which  the  ilio-femoral 
ligament  has  suffered  complete 
disrupti<:)n. 

In  reducing  either  of  the  re- 
gular dislocations  the  limb  must 
be  flexed,  in  order  to  relax  the 
ilio-femoral  ligament;  but  if 
other  portions  of  the  capsule  are 
not  sufficiently  torn  to  admit  the  return  of  the  head  within  its  socket,  it 
must  be  torn  by  circumduction  of  the  limb.  After  flexion,  and 
perhaps  circumduction,  the  reduction  may  be  completed  by  rotation, 
or  by  extension  of  the  thigh  at  right  angles  with  the  anterior  surface 
of  the  body. 

The  dorsal  dislocation  owes  its  inversion  to  the  external  fasciculus 
of  the  ilio-femoral  ligament. 

In  the  ischiatic  dislocation,  "dorsal  below  the  tendon"  (^i^re/ow), 
the  head  is  arrested,  in  extension,  by  the  tendon  of  the  obturator  and 
the  subjacent  capsule. 

The  flexion  and  eversion  of  the  limb  in  the  thyroid  dislocation  are 
due  to  the  ilio-femoral  ligament. 

•  Year  Book  of  Med.  and  Svirg.  for  1864.     Sydenham  Soc.  PuWications  ;  from 
Arcliiv.  of  Clinical  Sur<rery,  vol.  iv.  part  i.,  Berlin.  I860. 
2  Von  Pitha's  and  Biilrotli's  Surgery,  vol.  iv.,  I860. 


nio-femoral  ligament.     (Bigelow.) 


638 


DISLOCATIONS    OF    THE    THIGH. 


In  the  pubic  dislocation  the  ascent  of  the  limb  is  finally  arrested 
by  the  ilio-femoral  ligament. 


Fiff.  275. 


Dislocation  wpon  the  dorsum  ilii.    (Bigelow.) 

The  conclusion  at  which  we  ought  to  arrive  seems  to  be  that  in 
some  cases,  the  capsule  being  completely  or  almost  completely  torn 
away,  the  muscles  ofier  the  only  resistance  ;  and  that  according  to  the 
exact  position  of  the  limb  or  degree  of  displacement,  one  or  another 
set  of  muscular  fibres  will  oppose  the  reduction;  and  in  other  cases, 
the  muscles  being  paralyzed  by  the  shock,  or  by  anaesthetics,  the  par- 
tially torn  capsule,  into  which  the  head  of  the  bone  is  received  as  in  a 
button-hole,  or  the  Y  ligament,  prevents  its  free  return  into  the  socket. 

Symptoms. — Sir  Astley  Cooper  affirmed  that  the  limb  was  sometimes 
found  shortened  in  this  dislocation  to  the  extent  of  three  inches.  Liston, 
B.  Cooper,  Gibson,  and  others  repeat  the  affirmation.  Chelius  places 
the  extreme  of  shortening  at  two  and  a  half  inches ;  Miller,  at  two 
inches;  while  Malgaigne  declares  that  he  has  never  seen  the  limb 
shortened  more  than  half  an  inch,  and  that  in  some  cases  it  is  not 
shortened  at  all,  and  the  very  opposite  opinions  entertained  by  other 
surgeons  he  attributes  to  errors  in  the  measurement.  I  am  certain, 
however,  that  Malgaigne  has  fallen  into  some  error,  and  that,  while 
the  average  shortening  is  about  one  inch  or  one  inch  and  a  half,  it 
does  occasionally  reach  three  inches. 

The  thigh  is  rotated  inwards,  adducted  and  slightly  flexed  upon 
the  pelvis.  The  great  toe  of  the  dislocated  limb,  when  the  patient 
stands  erect  (and  in  this  position  the  examination  ought,  if  possible, 
to  be  made),  rests  upon  the  instep  of  the  foot  of  the  souud  limb,  and 


UPWARDS    AND    BACKWARDS    OX    THE    DORSUM    ILII.      639 


.  376. 


the  knee  touches  the  opposite  thigh  near  the  upper  margin  of  the  pa- 
tella. It  must  not  be  supposed,  however,  that  the  position  of  the  limb 
is  in  all  cases  precisely  such  as  we 
have  described.  Indeed  the  degree 
of  rotation,  adduction,  flexion,  &c., 
will  vary  according  as  the  head  of 
the  femur  is  more  or  less  displaced, 
the  capsule,  including  the  liga- 
ments, more  or  less  torn,  or  as  it 
may  be  torn  in  its  upper  or  lower 
margins,  as  the  muscles  may  be  ac- 
tually rent  asunder,  or  only  put  upon 
the  stretch,  and  perhaps  also  accord- 
ing to  the  amount  of  injury  and  con- 
sequent relaxation  which  they  may 
have  sustained  from  the  shock.  The 
thigh  can  be  easily  flexed  ;  adduc- 
tion is  more  difficult,  but  abduction 
is  almost  impossible,  except  to  a 
very  limited  extent :  the  body  of  the 
patient  is  a  little  bent  forwards,  the 
roundness  of  the  hip  is  lost  in  conse- 
quence of  the  relaxation  of  the  glu- 
tei! muscles ;  the  trochanter  major  is 
depressed,  and  approaches  the  ante- 
rior superior  spinous  process  of  the 
ilium  ;  and  if  the  patient  is  not  fat, 
and  swelling  has  not  already  taken 
place,  the  head  of  the  femur  may 
be  felt  in  its  new  position  rotating 
under  the  hand  when  the  limb  is 
turned  inwards  or  outwards,  but 
especially  may  it  be  felt  when,  by 
flexing  or  extending  the  limb,  the 
head  is  made  to  move  downwards 
and  upwards,  upon  the  dorsum  ilii. 

As  we  have  already  said,  this  examination  ought  to  be  made,  if 
possible,  in  the  erect  posture;  after  which,  it  will  be  well  to  place  the 
patient  alternately  upon  his  back,  upon  his  sound  side,  and  upon  his 
belly,  until  the  diagnosis  is  rendered  complete. 

The  differential  diagnosis  between  dislocation  upon  the  dorsum  ilii 
and  a  fracture  of  the  neck  of  the  femur  may  be  briefly  stated  as  follows. 

In  fracture,  we  may  expect  to  find  crepitus ;  the  limb  is  in  most  cases 
mobile  ;  the  toes  are  generally  turned  out;  the  limb  is  shortened  mode- 
rately or  not  at  all ;  the  patient  is  sometimes  able  to  walk  for  a  short 
distance;  fractures  of  the  neck  of  the  femur  generally  occur  in  ad- 
vanced life. 

In  dislocation,  crepitus  is  not  often  present,  and  only  when  a  frac- 
ture coexists  ;  the  limb  is  immobile,  or  nearly  so  ;  the  toes  are  turned 
in;  the  limb  is  shortened  more;  the  patient  is  unable  to  bear  the 


Dislocation  upoa  the  dorsum  ilii. 


64:0 


DISLOCATIONS    OF    THE    THIGH, 


Fig.  277. 


weight  of  his  body  upon  his  foot  for  one  moment.  Skey,  however,  says 
he  has  seen  a  patient  with  a  recent  dislocation,  who  walked  one-quar- 
ter of  a  mile,  to  the  hospital.  I  do  not  think  any  other  similar  case  is 
upon  record.  Dislocations  of  the  femur  generally  occur  in  middle  life. 
I  have  been  frequently  told  by  persons  who  have  called  upon  me 
with  children  suffering  under  hip-disease,  that  they  had  been  informed 
the  hip  was  out,  and  they  expected  me  to  reduce  it.  In  two  or  three 
instances  they  have  blamed  their  surgeons  very  much,  because  they 
had  not  detected  the  accident  at  the  time  of  its  occurrence.  Norris,  of 
Philadelphia,  mentions  an  extraordinary  example  of  this  kind,  as 
having  been  presented  at  the  Pennsylvania  Hospital,  and  which  ought 
to  serve  as  a  sufficient  warning  to  prevent  similar  mistakes  in  future. 
A  lad,  twelve  years  old,  was  brought  to  the  hospital  from  a  neighbor- 
ing State,  who  a  short  time  previous  had  been  suddenly  attacked  with 
lameness  in  his  right  limb,  and  which,  by  his  friends,  was  attributed 
to  some  injury  received  in  play.  Two  physicians,  who  had  been  called 
to  see  the  boy,  pronounced  him  to  be  laboring  under  dislocation  of 
the  hip,  and  had  made  two  strong  efforts  with  the  pulleys,  to  reduce  it ; 
but,  after  causing  great  suffering,  they  gave  up  all  hopes  of  ever  re- 
placing the  bone,  and  sent  him  to  Philadelphia.  The  symptoms  were 
plainly  those  of  hip-joint  disease  in  its  early  stage.     The  attitude  was 

that  assumed  by  those  laboring  under  this 
affection ;  the  leg  seemed  lengthened,  but 
a  careful  measurement  showed  that  it  was 
of  the  same  length  with  the  other;  the  but- 
tock was  flattened,  and  the  motions  of  the 
joint  were  tolerably  free  but  painful.' 

If  the  supposed  dislocation  occurs  in  a 
child,  or  in  a  person  under  ten  years  of  age, 
we  ought  to  take  especial  pains  to  ascertain 
that  it  is  not  a  separation  of  the  epiphysis, 
of  which  accident  we  have  mentioned  some 
examples  when  speaking  of  fractures  of  the 
neck  of  the  femur. 

Examples  have  occasionally  been  re- 
ported of  "everted  dorsal  dislocations,"  in 
which  most  of  the  usual  signs  of  a  dorsal 
dislocation  are  present,  except  that  the  limb 
is  everted,  and  sometimes  slightly  abducted. 
Bigelow  attributes  this  condition  to  a  rup- 
ture of  the  outer  fibres  of  the  ilio-femoral 
ligament,  and  he  affirms  that  under  these 
circumstances  the  limb  may  be  found  in- 
verted, but  it  is  also  easily  everted ;  the 
foot  may  be  slightly  everted,  it  may  lie  flat 
upon  the  bed,  or  it  may  even  point  back- 
TT     »  J  J      ,  J-  ,     ,.      .T,.        wards. 

tverted  dorsal  dislocation.  (Bige-  ,^, 

low.)  1  be  treatment  of  the  everted  dorsal  dis- 


•  Norris,  Amer.  Journ.  Med.  Sci.,  vol.  xxv.  p.  280. 


UPWARDS    AND    BACKWARDS    ON    THE    DORSUM    ILII.      641 

location  consists  in  reducing  it  first  to  an  ordinary  dorsal  dislocation 
bj  flexion  and  rotation  inwards,  aided  by  adduction,  if  necessary. 

Prognosis. — Boyer  says  the  limb  remains  always  weaker  than  the 
other,  the  round  ligament  never  uniting  completely ;  and  that  inflam- 
mation of  the  cartilages  and  synovial  glands  may  ensue,  ending  in 
caries  of  the  joint.  Such  results  have,  indeed,  been  occasionally  met 
with,  nor  are  examples  wanting  in  which  more  rapid  inflammation, 
resulting  in  the  formation  of  acute  abscesses,  has  followed,  but  these  are 
only  rare  accidents.  In  the  large  majority  of  cases  the  patients  recover 
speedily,  and  in  the  course  of  a  few  weeks,  or  months  at  most,  the 
limb  seems  to  be  as  sound  and  as  useful  as  before. 

Examples  of  non-reduction,  however,  from  an  error  of  diagnosis,  or, 
what  is  more  pertinent  to  our  present  purpose,  from  a  failure  to 
accomplish  the  reduction  where  the  attempt  has  been  made,  are 
numerous.  Fortunately,  Mr.  Chelius,  the  author  of  a  most  excellent 
"  System  of  Surgery,^''  to  which  we  have  already  had  frequent  occasion 
to  riefer,  has  sufficient  reputation,  the  world  over,  to  enable  him  to 
bear  a  portion  of  these  failures,  without  injury  to  himself  or  to  the 
profession  which  he  so  eminently  adorns.  We  shall  therefore  make 
no  apology  for  reporting  the  following  unsuccessful  attempt  to  reduce 
a  dislocation  of  the  hip  in  which  Mr.  Chelius  himself  was  the  operator. 

On  the  11th  of  June,  1851,  John  Mauren,  a  German,  £et.  19,  called 
at  my  office  and  related  as  follows:  "When  ten  years  old,  I  fell  from 
a  tree,  a  height  of  six  feet,  and  dislocated  my  left  hip.  I  was  then 
living  twelve  miles  from  Heidelberg,  and  I  was  immediately  taken 
there,  but  I  did  not  see  Mr.  Chelius  until  the  next  morning.  He  took 
me  to  the  University,  and,  before  the  medical  class,  attempted  to  reduce 
it,  but  he  could  not.  During  several  weeks  following,  he  tried  six 
times,  using  pulleys,  &c.,  but  he  could  never  succeed." 

On  examination,  I  found  the  limb  shortened  two  inches,  the  head  of 
the  femur  lying  upon  the  dorsum  ilii ;  the  knee  was  turned  in,  but 
the  toes  were  inclined  a  little  outwards.  He  was  able  to  walk  rapidly, 
of  course  with  a  manifest  halt,  yet  without  pain  or  discomfort. 

Treatment. — Eegarding  dislocations  of  the  femur  upon  the  dorsum 
ilii  as  the  type  of  all  the  coxo- femoral  dislocations,  the  remarks  which 
we  shall  make  under  this  section  may  be  considered  applicable,  with 
only  certain  qualifications,  to  all  the  others. 

We  shall  arrange  the  various  methods  of  reduction  which  have 
been  employed  by  surgeons  under  two  principal  heads,  namely,  mani- 
pulation and  extension.  It  is  not  possible,  however,  to  classify  rigidly 
the  different  procedures,  so  as  to  bring  them  under  these  two  simple 
divisions,  without  some  violence;  since  neither  manipulation  nor  ex- 
tension has  usually  been  employed  alone,  but  almost  always  some 
degree  of  extension  has  been  recommended  in  connection  with  the 
maaipulation ;  if  not  in  the  first  instance,  at  least  in  the  event  of  the 
failure  of  manipulation  alone;  while,  on  the  other  hand,  extension  is 
seldom  if  ever  practised  without  manipulation.  We  intend,  then,  to 
imply  by  these  designations  respectively,  that  either  manipulation  or 
extension  has  constituted  the  prevailing  feature  in  the  treatment. 

Eeduction  by  manipulation  dates  from  the  earliest  records  of  our 


642  DISLOCATIONS    OF    THE    THIGH. 

science.  Says  Hippocrates:  "In  some  the  thigh  is  reduced  with  no 
preparation,  with  slight  extension  directed  by  the  hands,  and  with 
slight  movement ;  and  in  some  the  reduction  is  effected  by  bending 
the  limb  at  the  joint  and  making  rotation."^ 

Kichard  Wiseman,  who  wrote  in  1676,  speaks  as  follows:  "If  the 
thigh-bone  be  luxated  inwards,  and  the  patient  young  and  of  a  tender 
constitution,  it  may  be  reduced  by  the  hand  of  the  chirurgeon,  viz.,  he 
must  lay  one  hand  on  the  thigh,  and  the  other  on  the  patient's  leg,  and 
having  somewhat  extended  it  toward  the  sound  leg,  he  must  suddenly 
force  the  knee  up  toward  the  belly,  and  press  back  the  head  of  the 
femur  into  its  acetabulum,  and  it  will  snap  in.  For  there  is  no  need 
of  so  great  extension  in  this  kind  of  luxation;  for  the  most  consider- 
able muscles  being  upon  the  stretch,  the  bowing  of  the  knee  as  afore- 
said reduceth  it;  yet  in  rough  bodies  it  may  require  stronger  exten- 
sion."* 

Eichard  Boulton  repeated,  in  1713,  almost  the  same  instructions, 
affirming  that  this  plan  was  applicable  especially  to  dislocations  in- 
wards, in  the  case  of  "young  and  tender  children."^ 

In  1742  Daniel  Turner  declared  that  he  had  reduced  three  disloca- 
tions of  the  hip,  one  of  which  was  a  backward  dislocation,  by  a 
method  combining  extension  with  manipulation,  but  alone  "  by  the 
strength  of  the  arm  or  without  any  other  instrument."  Extension 
and  counter-extension  being  made  by  assistants,  and  "  as  soon  as  the 
surgeon  perceives  the  bone  moving  out,"  says  Turner,  "let  him  take 
his  opportunity,  giving  orders  to  the  extenders  below  suddenly  to  lift 
up  the  patient's  thigh  toward  his  belly,  pressing  with  his  hands, 
either  to  the  right  or  left,  as  the  situation  of  the  same  requires,  and 
therewith  force  back  its  head  toward  the  acetabulum,  whereunto  it 
will,  flipping  over  the  tip  of  the  cartilage,  snap  sometimes  with  a  loud 
noise,"* 

Thomas  Anderson,  surgeon,  of  Leith,  in  Scotland,  was  called,  in 
Sept.  1772,  to  see  a  man  who  had  dislocated  his  left  femur  into  the 
foramen  thyroideum.  When  he  arrived  four  other  surgeons  were 
present,  and  prepared  to  use  the  pulleys,  which  they  did  in  his  pre- 
sence several  times,  but  to  no  purpose.  After  examining  the  limb 
carefully,  "  I  was  convinced,"  says  Mr.  Anderson,  "  that  attempting 
the  reduction  in  the  common  method,  with  the  thigh  extended,  was 
improper,  as  the  muscles  were  all  put  on  the  stretch,  the  action  of 
which  is,  perhaps,  sufficient  to  overbalance  any  extension  we  can  ap- 
ply. But  by  bringing  the  thigh  to  near  a  right  angle  with  the  trunk, 
by  which  the  muscles  would  be  greatly  relaxed,  I  imagined  that  the 
reduction  might  more  readily  take  place,  and  with  much  less  exten- 
sion. 

"When  I  made  this  examination,  he  was  lying  on  a  table  on  his 

'  Works  of  Hippocrates,  Syd.  ed.,  vol.  ii.  p.  643. 

2  Eight  Chirurgical  Treatises.  By  Richard  Wiseman,  Serjeant-Chirurgeon  to 
King  Charles  II.     London,  1676.     Book  vii.  chap.  viii. 

'  A  System  of  Rational  and  Practical  Surgery.  By  Richard  Boulton.  London, 
1713,  p.  346.  >=    J         J 

^  The  Art  of  Surgery,  by  Daniel  Turner,  London,  1743,  vol.  ii.  p.  339. 


UPWARDS    AND    BACKWARDS    ON    THE    DORSUM    ILII.      6-43 

back.  I  raised  the  thigh  to  about  a  right  angle  with  the  trunk,  and, 
with  my  right  hand  at  the  ham,  Laid  hold  of  the  thigh,  and  made  what 
extension  I  could.  From  this  trial  I  found  I  could  dislodge  the  head 
of  the  bone.  At  the  same  time  that  I  did  this,  with  mj  left  hand  at 
the  head  and  inside  of  the  thigh,  I  pressed  it  toward  the  acetabulum, 
while  my  right  gave  the  femur  a  little  circular  turn,  so  as  to  bring 
the  rotula  inwards  to  its  natural  situation  ;  and  on  the  second  attempt 
it  went  in  with  a  snap  observable  to  the  gentlemen  standing  around, 
but  more  so  to  the  poor  man,  who  instantly  cried  out  he  was  well  and 
free  from  pain.  His  knees  could  then  be  brought  together ;  the  legs 
were  of  the  same  length,  and  the  foot  in  its  natural  situation.  The 
knees  were  kept  together  for  some  time,  with  a  roller,  to  confine  the 
motion  of  the  thigh ;  and  in  three  weeks  he  was  at  his  work,  without 
the  least  stiffness  in  the  joint." 

■  Subsequently  Mr.  Anderson  reduced  by  a  similar  method  a  dislo- 
cation upon  the  dorsum  ilii  in  a  child  eight  years  old,  and  which  had 
been  out  nineteen  days.^ 

Says  Pouteau,  in  a  memoir  on  dislocations  of  the  thigh  upwards 
and  outwards :  "  We  observe  then,  first,  that  the  thigh  ought  to  be 
flexed  to  a  right  angle  with  the  body  during  the  extension  and  coun- 
ter-extension ;  second,  that  we  ought  to  rotate  the  thigh  from  within 
outwards,  when  the  extension  appears  to  be  sufficient ;  third,  that  this 
position  puts  into  relaxation,  as  much  as  possible,  the  triceps  and 
gluteal  muscles  which  oppose  the  chief  resistance  to  the  extension, 
thus  saving  the  patient  from  excessive  pain  ;  fourth,  that  the  flexion 
of  the  thigh  places  the  head  of  the  bone  in  the  best  position  for  a  re- 
turn to  the  cotyloid  cavity  during  extension ;  fifth,  that  feeble  exten- 
sion suffices  for  the  reduction,  because  all  of  the  muscles  of  the  thigh 
are  relaxed."^ 

On  the  7th  of  Jan.  1811,  Dr.  Philip  Syng  Physick,  of  Philadelphia, 
reduced  an  outward  dislocation  of  the  hip,  after  extension  had  failed, 
by  flexing  the  thigh  to  a  right  angle  with  the  body,  and  then  giving 
to  the  limb  "  an  outward  circular  sweep."^ 

So  early  as  1815,  and  perhaps  much  earlier,  Nathan  Smith,  Prof,  of 
Surgery  in  the  New  Haven  Medical  College,  taught  that  the  only  cor- 
rect mode  of  reducing  a  dislocation  upon  the  ilium  was  to  flex  the 
leg  upon  the  thigh,  the  thigh  upon  the  pelvis,  and  then  to  carry  the 
limb  diagonally  to  the  opposite  side,  from  whence  it  was  to  be  brought 
outwards  and  downwards;^  and  in  1824,  Dr.  Smith,  being  under  oath, 
affirmed  as  follows  :  "  I  do  not  think  that  the  mechanical  powers,  such 
as  the  wheel  and  axle,  or  the  pulleys,  are  necessary  to  reduce  a  dislo- 
cated hip,  or  any  other  dislocation."  He  further  adds  that  he  once 
reduced  a  dislocation  upon  the  dorsum  ilii  after  he  had  pulled  in  every 
direction  but  the  right,  "  by  carrying  the  knee  towards  the  patient's 

'  Anderson,  Medical  Commentaries,  Edinburgh,  1776,  vol.  ii.  pp.  2G1-4. 

2  Vidal  (de  Cassis) ;  from  (Euvres  posthumes  de  Pouteau,  Paris,  1783. 

3  Physick,  Dorsey's  Surg.,  1813,  vi.  p.  242.  Mem.  of  Nathan  Smith,  1831,  p.  172. 
Phelps's  paper,  in  Trans.  New  York  State  Med.  Soc,  1856,  p.  169. 

*  Trans.  N.  H.  St.  Med.  See,  1854,  p.  55. 


644:  DISLOCATIONS    OF    THE    THIGH. 

face."^  Subsequently  the  son  of  Dr.  Smith,  Nathan  R,  Smith,  the 
present  distinguished  teacher  of  surgery  in  the  Medical  College  at 
Baltimore,  gave  a  more  full  account  of  his  father's  method,  illustrating 
his  views  of  the  pathology  of  these  dislocations,  and  the  mechanism 
of  their  reduction,  by  several  drawings.  It  must  be  noticed,  however, 
that  Dr.  Nathan  Smith  left  no  written  explanation  of  his  views  and 
practice,  except  that  which  is  to  be  found  in  the  affidavit  already 
quoted,  and  that  the  account  published  by  his  son  is  from  memory, 
and  it  is  given  as  follows:  "The  patient  being  prepared  for  the 
operation  by  whatever  means  may  be  deemed  necessary,  may  be  placed 
in  an  attitude  convenient  for  the  operation,  with  the  body  securely 
fixed,  by  placing  him  in  the  horizontal  posture,  on  a  narrow  table 
covered  with  blankets,  and  on  the  sound  side.  To  the  table  his  body 
should  be  firmly  fixed,  and  this  can  be  conveniently  done  by  folding 
a  sheet  several  times,  lengthways — then  applying  the  middle  of  the 
broad  band  thus  made  to  the  inner  and  upper  part  of  the  sound  thigh 
— carrying  its  extremities  under  the  table,  crossing  them  beneath  it, 
and  then  carrying  them  obliquely  up  and  crossing  them  firmly  over 
the  trunk,  above  the  injured  hip.  The  ends  may  then  be  secured 
beneath  the  table.  To  support  the  trunk  the  more  firmly,  a  pillow  may 
be  placed  on  each  side  of  it  upon  the  table,  and  be  included  in  the  band- 
age. Should  the  operator  design  to  employ  any  degree  of  extension, 
a  counter-extending  band  may  be  placed  in  the  perineum,  and  carried 
up  to  the  extremity  of  the  table,  be  fixed  to  some  more  firm  body,  or 
held  by  the  hands  of  assistants. 

"The  operator  now  standing  on  the  side  to  which  the  patient's  back 
presents,  grasps  the  knee  of  the  dislocated  member  with  his  right 
band  (if  the  left  femur  be  dislocated — vice  versa,  if  the  right),  and  the 
ankle  with  the  left.  The  first  effort  which  he  makes  is  to  flex  the  leg 
upon  the  thigh,  in  order  to  make  the  leg  a  lever  with  which  he  may 
operate  on  the  thigh-bone.  The  next  movement  is  a  gentle  rotation 
of  the  thigh  outwards,  by  inclining  the  foot  toward  the  ground,  and 
rotating  the  knee  outwards.  Next  the  thigh  is  to  be  slightly  abducted 
by  pressing  the  knee  directly  outwards.  Lastly,  the  surgeon  freely 
flexes  the  thigh  upon  the  pelvis  by  thrusting  the  knee  upwards 
toward  the  face  of  the  patient,  and  at  the  same  moment  the  abduction  is 
to  he  increased. 

"  Professor  N.  Smith  regarded  the  free  flexion  of  the  thigh  upon 
the  pelvis  as  a  very  important  part  of  the  compound  movement.  lie 
believed  that  it  threw  the  head  of  the  bone  downwards,  behind  the 
acetabulum,  where  the  margin  of  the  cup  is  less  prominent,  and  over 
which,  therefore,  the  abductor  muscles  would'  drag  it  with  less  diffi- 
culty into  its  place. 

"  The  operator  may  slightly  vary  these  movements,  as  he  increases 
them,  so  as  to  give  some  degree  of  rocking  motion  to  the  head  of  the 
OS  femoris,  which  will  thereby  be  disengaged  with  the  more  facility 
from  its  confined  situation  among  the  muscles."^ 

'  Report  of  the  Trial  of  an  Action  for  Malpractice.     Lowel  v.  Faxon  and  Hawks, 
Macliias,  Maine,  1824;  also  Buff.  Med.  .Tourn.,  vol.  xiii.  p.  515. 
2  Medical  and  Surgical  Memoirs,  by  Nathan  Smith,  late  Prof,  of  Surgery,  &c., 


UPWAEDS    AND    BACKWARDS    OX    THE    DOESUM    ILII.      645 

Dr.  Luke  Howe,  of  Boston,  who  was  a  pupil  of  Nathan  Smith's, 
gives  the  following  account  of  the  method  practised  bj  him  success- 
fully, about  the  year  1820,  and  which  method,  he  says,  was  recom- 
mended by  his  preceptor:  "The  patient  was  permitted  to  lie  on  his 
back  on  the  bed  where  I  found  him,  the  knee  of  the  luxated  limb 
turned  in  and  over  the  other.  I  raised  the  knee  in  the  direction  it 
inclined  to  take,  which  was  toward  the  breast  of  the  opposite  side, 
till  the  descent  of  the  head  of  the  bone  gave  an  inclination  of  the 
knee  outwards,  when  I  made  use  of  the  leg,  being  at  right  angle  with 
the  thigh,  as  a  lever  to  rotate  the  latter  and  turn  the  head  of  it  in- 
wards.    It  then  readily  returned  to  its  socket,  with  an  audible  snap. 

Fio;.  278. 


Nathan  Smith's  method  of  reduction  by  manipulation.     (From  Smith's  "  Memoirs. ") 

During  this  operation,  the  two  assistants  who  had  been  placed  to 
make  the  lateral  extension  and  counter-extension,  if  ultimately  re- 
quired, were  directed  to  draw  moderately  at  their  towels.  How  much 
of  the  success  of  the  operation  is  to  be  imputed  to  their  extension,  and 
the  rotation  of  the  thigh  by  the  leg,  I  am  unable  to  determine  ;  but  as 
Dr.  Smith  succeeded  without  the  aid  of  either,  and  as  the  head  of  the 
femur  seemed  to  descend  by  an  easy  and  natural  process,  I  am  inclined 
to  believe  that  all  that  is  necessary,  in  such  cases,  is  to  elevate  the 
knee,  when  the  ilium,  the  muscles  attached  to  it,  and  perhaps  the 
ligament,  become  the  natural  fulcrum,  over  which  the  thigh,  as  a 
lever,  acts  to  bring  the  head  down  and  inwards  into  the  socket.'" 

in  Yale  College.  Edited  by  Nathan  R.  Smith,  Prof,  of  Surgery  in  Univ.  of  Mary- 
land.    Baltimore,  1831,  pp.  1(5:5-182. 

'  Howe,  Boston  Med.  and  Surg.  Journ.,  vol.  xxii.  p.  249,  May,  1840. 


646  DISLOCATIONS    OF    THE    THIGH. 

Kluge,  in  1825,  combined  moderate  extension  with  manipulation, 
by  flexing  both  the  leg  and  thigh,  while  at  the  same  moment  the 
thigh  was  abducted  and  the  knee  rotated  inwards.*  Wathman,  in 
1826,  directed  that  in  this  dislocation  the  limb  should  be  seized  by 
the  knee  and  ankle  and  slowly  lifted  forwards  until  it  came  to  a  right 
angle  with  the  long  axis  of  the  body ;  when,  if  the  outward  "  self- 
twisting  of  the  thigh"  occurs,  "  which  cannot  be  prevented  by  fast 
holding,"  the  movement  of  the  head  of  the  bone  is  declared,  and  it 
will  only  remain  for  the  surgeon  to  let  down  the  thigh  gradually 
upon  the  bed  so  that  the  two  limbs  will  come  side  by  side,  and  the 
reduction  will  be  accomplished,^ 

Eust  recommended  also,  in  1826,  a  similar  plan,  combining  mode- 
rate extension  by  the  hands,  with  flexion  and  abduction  of  the  thigh.^ 

Colombat,  whose  opinions  date  from  1830,  suggested  that  the  pa- 
tient should  lay  himself  forwards  upon  a  bed  or  table,  no  higher  than 
his  hips,  with  the  sound  leg  and  foot  resting  upon  the  floor,  and  that 
then  the  surgeon  seizing  the  foot  with  one  hand,  so  as  to  flex  the  leg, 
should,  with  the  other  hand,  exercise  a  moderate  degree  of  extension, 
and  at  the  same  time  move  the  limb  to  the  right  or  to  the  left,  backwards 
and  forwards,  in  order  to  disengage  the  head  of  the  femur ;  and,  finally, 
that  he  should  communicate  to  the  thigh  a  sudden  movement  of  cir- 
cular rotation,  either  from  within  outwards,  or  from  without  inwards, 
as  the  surgeon  may  choose.^ 

Collin  states  that,  in  1833,  he  had  reduced  four  dislocations  of  the 
hip  by  a  method  very  similar  to  this  recommended  by  Colombat.^ 

Dr.  William  Ingalls,  of  Chelsea,  Mass.,  reduced  a  compound  dislo- 
cation of  the  femur,  in  which  the  head  of  the  bone  rested  upon  the 
pubes,  after  an  unsuccessful  attempt  had  been  made  to  reduce  it  by 
extension.  "An  assistant,  taking  the  ankle  of  the  dislocated  limb  in 
his  right  hand,  and  placing  his  left  in  the  ham,  bent  the  leg  at  right 
angles  upon  the  thigh,  and  the  thigh  upon  the  pelvis,  then  lilting  with 
a  power  little  more  than  sufficient  to  elevate  the  whole  limb,  he  car- 
ried it  to  its  greatest  state  of  abduction,  at  the  same  time  rotating  the 
femur  inwards,  while  Dr.  Ingalls  passed  his  thumb  through  the  wound, 
and  pressing  upon  the  head  of  the  femur,  directed  it  toward  the  ace- 
tabulum. At  this  moment  he  directed  the  limb  to  be  forced  toward 
its  fellow,  by  which  the -reduction  was  effected  with  the  greatest  pos- 
sible ease  and  elegance."® 

Similar  methods  of  reduction,  with  only  such  slight  variations  as 
scarcely  deserve  a  special  notice,  have  been  suggested  and  practised 
from  time  to  time  by  Palletta,  in  1818;^  Desprez,  in  1835;^  Vial,  in 
1841  f  Fischer,  Mahr,  and  Clark,  in  1849.*« 

'  Chelius's  Surg.,  by  South,  Amer.  eel.,  vol.  li.  p.  241. 

2  Chelius's  Surg.,  by  South,  Amer.  ed.,  vol.  ii.  p.  239. 

3  Ibid.,  p.  241,  note  by  South. 

^  Malgaigne,  op.  cit.  vol.  ii.  p.  825. 

5  Malgaigne,  op.  cit.,  p.  823. 

6  Ingalls,  Bransby  Cooper's  ed.  of  Sir  Astley's  English  ed.,  1842,  and  Amer.  ed., 
1852. 

7  Chelius's  Surg. ;  note  by  South.  »  Malgaigne.  ^  Ibid. 
'0  Dublin  Med.  Press,  Dec.  3,  1851.     jSTew  York  Journ.  Med.,  March,  1853. 


UPWAEDS    AND    BACKWAEDS    ON    THE    DOESUM    ILII.      6i7 

In  1851,  Dr.  W.  W.  Reid,  of  Rochester,  N.  Y,,  published  an  account 
of  the  method  practised  by  himself  successfully  in  three  cases  of  dis- 
location upon  the  dorsum  ilii,  the  first  of  which  dated  from  the  year 
1844.  His  method,  as  applied  to  a  dislocation  upon  the  dorsum  ilii, 
consists  in  "flexing  the  leg  upon  the  thigh,  carrying  the  thigh  over 
the  sound  one,  upwards  over  the  pelvis  as  high  as  the  umbilicus,  and 
then  abducting  and  rotating  it."^ 

Dr.  Markoe,  of  New  York,  adopts  the  same  procedure,  except  that 
when  the  limb  has  been  sufficiently  flexed  and  abducted,  he  directs 
that  the  limb  shall  be  gradually  brought  down,  and  he  affirms  that  it 
is  during  this  last  manoeuvre  that  he  has  usually  found  the  bone  re- 
sume its  place  in  the  socket.^ 

Bigelow,  of  Boston,  declares,  as  has  already  been  stated,  that  in  all 
the  regular  dislocations,  that  is  to  say,  in  all  those  dislocations  in 
which  the  ilio-femoral  ligament  is  not  torn,  the  thigh  must  be  first 
flexed,  in  order  to  relax  this  ligament,  and  then  reduction  may  be 
effected  by  extension  directly  forwards,  the  thigh  being  at  a  right 
angle  with  the  body,  or  by  rotation.  In  some  cases,  where  there  is 
probably  only  a  button-hole  slit  in  the  capsule,  free  circumduction 
may  be  required  in  order  that  the  capsule  may  be  torn  more  freely. 

Fiar.  279. 


Relaxation  of  the  ilio-femoral  ligament  by  flexion.     (Bigelow.) 

His  method  of  reducing  the  dislocation  upon  the  dorsum  ilii,  is  to 
flex  the  thigh  upon  the  abdomen,  abduct  and  then  rotate  outwards ; 
or,  to  flex,  then  adduct  and  rotate  a  little  inwards,  to  disengage  the 
head  of  the  bone  from  behind  the  socket,  then  abduct  and  pull  di- 


>  Reid,  Buffalo  Med.  Journ.,  vol.  vii.,  Aug.  1851,  pp.  129-143. 
2  Markoe,  New  York  Journ.  Med.,  Jan.  1855. 


648 


DISLOCATIONS    OF    THE    THIGH. 


rectly  upwards.     When  necessary,  circumduction  is  practical  to  la- 
cerate the  capsule  more  completely. 

Eeduction  by  extension  dates  from  a  period  equally  early  with  re- 
duction by  manipulation.  Hippocrates  recommended,  when  other  and 
gentler  means  had  failed,  to  make  extension  and  counter-extension  ; 
the  extending  bands  being  made  fast  above  the  knee  and  above  the 
ankle,  so  as  to  distribute  the  points  of  pressure;  and  the  counter-ex- 
tending bands  being  secured  around  the  chest  under  the  armpits,  and 
also,  if  thought  necessary,  in  the  perineum  of  the  sound  side. 


Fio;.  280. 


Hippocrates's  mode  of  reducing  dislocations  of  the  hip  by  extenf^ion. 

Among  the  methods  recommended  and  practised  by  Hippocrates, 
was  sitting  across  the  upper  round  of  a  ladder  with  a  weight  attached 
to  the  thigh  of  the  dislocated  limb;  or  suspending  the  patient  from  a 
sort  of  gallows  with  the  head  downwards,  and  if  the  weight  of  the 
patient's  own  body  proved  insufficient,  the  surgeon  might  add  his  also  ; 
a  method  which  Hippocrates  characterizes  as  "a  good,  proper,  and 
natural  mode  of  reduction,  and  one  which  has  something  of  displa}^  in 
it,  if  any  one  takes  delight  in  such  ostentatious  modes  of  procedure,"^ 

With  various  modifications  as  to  the  position  of  the  limb,  and  as  to 
the  points  upon  which  the  extending  and  counter-extending  forces  are 
to  be  applied,  and  with  differently  constructed  appliances,  surgeons 
have  continued  to  employ  extension  down  to  this  day. 

The  great  majority  have  regarded  flexion  of  the  thigh  as  essential 
to  success ;  some  holding  the  limb  only  slightly  flexed,  and  others  in- 
sisting that  a  flexion  should  be  increased  to  a  right  angle  with  the 
body. 

The  French  surgeons,  including  Boyer  and  Vidal  (de  Cassis),  prefer 
generally  to  apply  the  extending  bands  to  the  feet,  in  order  that  the 
muscles  of  the  thigh  may  not  be  stimulated  to  contraction  by  the  pres- 
sure of  the  bandages.     Mr.  Skey  adopts  the  same  method. 

Sir  Astley  Cooper,  Samuel  Cooper,  B.  Cooper,  Fergusson,  Miller, 
Pirrie,  Erichsen,  and  the  English  surgeons  generally,  make  fast  the 
lacq  above  the  knee.  J.  L.  Petit  and  Duverney,  among  the  French, 
and  Dorsey,  Gibson,  with  most  of  the  American  surgeons,  recommend 

'  Works  of  Hippocrates,  Syd.  ed.,  London,  vol.  ii.  p.  G41. 


UPWARDS    AND    BACKWARDS .  ON    THE    DORSUM    ILII.      649 


the  same,  but  Gerdy  seeks  to  multiply  the  points  of  application,  and 
for  this  purpose  secures  the  extending  band  to  the  whole  length  of 
the  leg,  and  to  a  small  portion  of  the  thigh  above  the  knee. 

The  counter-extending  bands  are  now  almost  universally  made  to 
operate  against  the  perineum  of  the  dislocated  limb,  but  Roux,  follow- 
ing the  practice  of  Hippocrates,  places  it  in  the  perineum  of  the  sound 
limb.     Gibson  recommends  the  same  practice. 

Lizars  recommends  that  sometimes  the  reduction  should  be  attempted 
by  simply  placing  the  heel  in  the  perineum  and  making  the  exten- 
sion with  the  hands,  very  much  as  Sir  Astley  Cooper  advises  us  to 
proceed  in  dislocations  of  the  humerus.  Morgan  and  Cock,  of  Guy's 
Hospital,  have  reduced  six  cases  of  dislocation  of  the  hip-joint  by 
placing  the  foot  between  the  thighs,  so  that  it  pressed  against  the 
upper  part  of  the  dislocated  bone,  and  thrust  it  away  from  the  pelvis; 
extension  and  rotation  of  the  limb  being  made  at  the  same  time  by 
assistants.^  Three  of  these  were  examples  of  dislocation  upon  the 
dorsum  ilii,two  upon  the  pubes,  and  one  into  the  foramen  thyroideum  ; 
and  most  of  them  had  occurred  in  weak  or  elderly  persons. 

Ambrose  Pare  was  among  the  first  to  recommend  the  use  of  pulleys 
for  the  reduction  of  dislocations.  Most  surgeons  since  his  day  have 
employed  them  for  the  purpose  of  making  extension  more  energetic 
and  steady,  and  that  it  might  be  longer  continued.  Sir  Astley  Cooper's 
plan  of  procedure  is  as  follows  : — 

The  patient  having  been  bled  freely  and  the  muscles  still  farther 

Fig.  281. 


Reduction  of  a  dislocation  on  the  dorsum  ilii,  by  pulleys.     (Sir  Astley  Cooper's  method.) 

relaxed  by  nauseating  doses  of  antimony  and  by  the  hot  bath,  he  is  to 
be  placed  on  his  back  upon  a  table  of  convenient  height  between  two 
staples  ;  a  strong  padded  leathern  girth  or  perineal  band,  constructed 
so  as  to  receive  the  thigh  and  to  press  at  the  same  moment  against  the 
perineum  and  the  outer  surface  of  the  pelvis,  is  then  applied  and  made 
fast  to  one  of  the  staples  situated  behind  the  patient  in  the  direction  of 
the  axis  of  the  limb.  A  wetted  linen  roller  is  next  to  be  tightly 
applied  just  above  the  knee,  and  upon  this  a  leathern  strap  is  to  be 
buckled,  having  two  short  straps  with  rings  at  right  angles  with  the 

'  Cock  and  Morgan,  Chelius,  op.  cit.,  vol.  ii.  p.  243,  note  by  South. 
42 


650 


DISLOCATIONS    OF    THE    THIGH. 


circular  part;  or,  instead  of  this,  a  round  towel  made  in  the  knot 
called  the  clove-hitch.  The  knee  is  to  be  slightly  bent,  but  not  quite 
to  a  right  angle,  and  brought  across  the  opposite  thigh  a  little  above 
the  knee.  The  pulleys  being  now  attached,  the  extension  is  to  be 
commenced. 

A  very  simple  and  efficient  mode  of  making  the  extension,  if  one 
has  not  the  pulleys,  is  to  employ  for  this  purpose  a  small  rope,  the 
ends  being  tied  together  and  the  rope  being  then  doubled  upon  itself 
once  or  twice,  so  as  to  make  four  or  eight  parallel  cords.  The  oppo- 
site ends  of  this  bundle  of  ropes  being  made  fast  to  the  limb  and  the 

Fig.  282. 


Reduction  of  a  dislocation  on  the  dorsum  ilii,  by  the  Spanish  windlass.     (Gilbert.) 

Staple,  the  extension  is  made  by  thrusting  a  stick  through  its  centre 
and  twisting  it. 

1  have  several  times  had  occasion  to  resort  to  this  plan  ;  and  indeed 
it  has  been  for  some  time  known  and  practised  among  surgeons  in  this 
country,^  having  been  first,  according  to  Prof.  Gilbert,  introduced  by 
Fahnestock,  of  Pittsburg,  Pa. 

Jarvis's  adjuster,  to  which  I  have  already  made  allusion  when  speak- 
ing of  dislocations  of  the  humerus,  has  been  often  used  with  success  in 
dislocations  of  the  hip  as  well  as  in  dislocations  of  the  shoulder.^  Its 
power  is  equal  to  that  of  the  pulleys,  while  the  direction  of  the  force 
can  be  varied  with  much  greater  ease.  The  most  serious  objections 
to  the  instrument  as  employed  for  the  reduction  of  dislocations,  are  its 
complexity  and  its  expensiveness. 

Mr.  Fergusson  says  that  the  Lajicet  for  July  26,  1845,  contains  a 
description  of  a  similar  apparatus  constructed  by  Coxeter  at  the 
suggestion  of  G.  N.  Epps  ;^  and  L'Estrange,  of  Dublin,  has  invented 
a  "  windlass"  for  making  extension,  with  a  "  forceps"  by  which  the 
extending  power  can  be  instantly  disengaged.*     Mr.  Bloxham's  "  dis- 

'  Gilbert,  of  Philadelphia,  note  to  Pirrie's  Surg.;  also  Amer.  Journ.  Med.  Sci., 
vol.  xxxT.,  April,  1845. 

2  Crandall,  Best.  Med.  and  Surg.  Journ.,  vol.  xxxix.  p.  77;  Atlee,  Trans.  Amer. 
Med.  Assoc,  vol.  iii.,  1850,  p.  357. 

3  Fergusson,  4th  Amer.  ed.,  p.  200.  ■»  Ibid.,  p.  198. 


UPWARDS    AND    BACKWARDS    ON    THE    DORSUM    ILII.      651 

location  tourniquet"  is  also  very  simple,  and  Mr.  Erichsen  affirms  that 
by  it  "  any  amount  of  extending  force  that  may  be  required  can  be 

Fia;.  283. 


Jarvis's  adjuster  applied  for  reduction  of  a  dislocation  of  the  hip. 

readily  set  up  and  maintained."^    Sedillot,  a  French  surgeon,  has  sug- 
gested that  when  pulleys  are  used,  we  should  measure  the  exact  power 

Fis.  284. 


Bloxbam's  "dislocation  tourniquet"  applied  for  reduction  of  a  dislocation  on  the  pubes. 

employed  in  the  reduction,  by  an  ingeniously  contrived  apparatus 
called  the  dynamometer.^  Such  an  instrument  might  occasionally 
be  useful  in  preventing  the  application  of  excessive  force,  especially 
when  the  patient  is  under  the  influence  of  an  anaesthetic. 

•  Erichsen,  Amer.  ed.,  1858,  p.  242. 

2  Amer.  Journ.  Med.  Sci.,  vol.  xv.  p.  530. 


652  DISLOCATIONS    OF    THE    THIGH. 

Finally,  without  attemptiug  to  determine  the  precise  relative  value 
of  these  different  procedures,  all  of  which  claim  for  themselves  the 
testimony  of  experience,  we  are  prepared  to  admit  that  no  one  of  them 
is  without  merit,  and  that  each  may  in  certain  cases  possess  advantages 
over  the  others.  Precisely  what  the  cases  are  to  which  each  individual 
method  may  be  especially  applicable,  we  believe  it  would  be  impossi- 
ble to  declare  unless  the  cases  were  actually  before  us;  and  even  then 
it  would  probably  be  found  diflEicult  often  to  say  which  was  the  best 
until  a  fair  trial  of  one  or  more,  and  a  final  success,  had  determined 
the  question.  The  time  has  not  yet  arrived  in  which  we  may  institute 
a  rigid  comparison  between  the  relative  merits  of  the  two  leading 
plans  of  reduction,  manipulation  and  extension,  for  while  it  is  true 
that  reduction  by  manipulation  has  been  practised  from  the  earliest 
day,  it  is  equally  true  that  extension  has  been  generally  preferred  and 
practised  by  surgeons  in  all  ages.  Indeed,  it  was  not  until  Dr.  Reid, 
of  Rochester,  again  called  the  attention  of  the  profession  to  this  sub- 
ject, illustrating  his  views  by  the  results  of  several  successful  experi- 
ments and  by  ingenious  arguments,  that  reduction  by  manipulation 
could  be  said  to  have  been  fairly  introduced  as  an  established  method 
of  practice  ;  a  large  majority  of  all  the  cases  upon  record  of  reduction 
by  manipulation  having  been  reported  since  the  year  1851,  the 
period  of  Dr.  Reid's  first  communication  to  the  Buffalo  Medical 
Journal. 

The  following  summary  of  a  paper  prepared  by  myself,  with  the 
view  of  determining,  if  possible,  the  relative  value  of  the  two  methods, 
and  exhibiting  an  analysis  of  sixty-four  cases  in  which  manipulation 
was  employed,  will  enable  the  reader  to  form  some  estimate  of  the 
difficulty  in  which  this  subject  is  involved ;  and  if  it  does  not  actually 
decide  a  moot-point,  it  will  at  least  demonstrate  that  the  method  by 
manipulation  is  not  without  its  hazards.^ 

"  Of  forty-one  cases  in  which  the  fact  is  stated,  twenty-eight  were 
reduced  on  the  first  attempt,  seven  on  the  second,  four  on  the  third, 
and  two  on  the  seventh.  In  seven  examples  the  head  of  the  femur 
has  been  thrown  from  one  position  to  another  upon  the  pelvis,  travel- 
ling from  the  dorsum  of  the  ilium  to  the  ischiatic  notch,  and  from 
thence  to  the  foramen  ovale;  or  directly  from  the  dorsum  to  the  fora- 
men, and  back  again  ;  or  in  other  directions,  according  to  the  character 
of  the  original  dislocation ;  in  some  instances  these  changes  being 
made  as  often  as  seven  times  in  succession.  In  the  majority  of  cases 
no  evil  consequences  seem  to  have  followed  upon  these  changes  of 
position.  One  of  my  own  cases  will  especially  serve  to  show  with 
what  impunity  sometimes  these  changes  may  be  made. 

"John  Caswell,  set.  28,  was  admitted  to  the  Buffalo  Hospital  of  the 
Sisters  of  Charity  on  the  13th  of  January,  1858,  with  a  dislocation  of 
the  left  femur  upon  the  dorsum  ilii,  which  had  occurred  six  days  be- 
fore. His  own  account  of  the  accident  was  that  he  was  standing  at 
the  bottom  of  a  well,  bent  forwards  until  his  body  was  at  a  right  angle 

'  Reduction  of  Dislocation  of  the  Femur  by  Manipulation.  By  the  Author. 
Buffalo  Medical  Journal,  Nov.  1857 ;  Feb.,  March,  June,  1859.  With  tables  con- 
structed by  my  very  intelligent  pupil,  Lucien  Damainville. 


UPWAEDS    AND    BACKWARDS    ON"    THE    DORSUM    ILII,      653 

with  his  thighs,  when  a  bucket  holding  live  hundred  pounds  of  earth 
fell  upon  his  back  and  hips.  No  attempt  had  been  made  to  reduce 
the  dislocation.  Five  times  in  succession  manipulation  made  by  ray- 
self  failed,  leaving  the  head  of  the  bone  each  time  upon  the  dorsum 
ilii ;  the  sixth  attempt,  made  with  the  addition  of  moderate  extension 
by  the  hands,  threw  the  head  into  the  foramen  thyroideum.  By  revers- 
ing the  movements,  it  was  easily  replaced  upon  the  dorsum  ilii.  The 
seventh  trial  was  made  in  the  same  manner,  except  that  when  I  sup- 
posed the  head  of  the  bone  to  be  opposite  the  lower  margin  of  the 
socket  I  did  not  permit  the  limb  to  turn  either  outwards  or  inwards, 
but  while  lifting  at  the  knee  with  my  hands,  with  sufficient  power  to 
raise  his  hips  from  the  table,  I  brought  the  limb  down  gradually  to  a 
line  parallel  with  the  opposite,  and  thus  finally  the  reduction  was 
accomplished.  No  pain  or  inflammation  followed,  and  in  two  weeks 
he  left  the  hospital ;  but  whether  he  was  able  to  walk  or  not  at  that 
time,  I  am  unable  to  say."^ 

Since  this  paper  was  written,  the  following  cases  have  come  to  my 
knowledge.  December  9th,  1865,  Dr.  James  E.  Wood  attempted,  at 
the  Bellevue  Hospital,  the  reduction  of  a  dislocation  of  the  femur 
upon  the  dorsum  ilii  of  five  months'  standing,  in  a  man  sixty  years 
of  age,  in  the  presence  of  Dr.  Sayre,  myself,  and  the  class  of  medical 
students.  The  patient  was  under  the  influence  of  ether.  Manipula- 
tion alone  was  employed.  Probably  half  an  hour  had  been  consumed 
in  the  various  efforts,  when,  at  a  moment  when  the  thigh  was  being 
forcibly  abducted,  the  neck  was  broken  within  the  capsule,  and  very 
close  to  the  head.  I  was  able  to  feel  the  head  of  the  bone  distinctly, 
after  the  fracture,  and  to  move  it  freely  separated  from  the  neck. 

Dr.  David  Prince,  of  Illinois,  who  was  present  at  the  time,  informed 
me  that  he  had  himself  fractured  the  neck  of  the  femur  in  attempting 
the  reduction  of  an  ancient  dislocation  of  the  hip  by  manipulation. 

In  Markoe's  paper,  published  in  the  New  Yorh  Journal  for  January, 
1855,  several  cases  similar  to  that  of  Caswell  are  reported,  in  which 
the  results  have  been  equally  fortunate ;  but  the  case  mentioned  as 
having  been  under  the  care  of  Dr.  Post,  had  a  more  serious  termina- 
tion. This  patient,  John  Kelly,  set.  21,  had  a  dislocation  into  the 
ischiatic  notch,  and  on  the  same  day  the  reduction  was  attempted  by 
manipulation.  On  the  first  trial  the  head  of  the  bone  was  thrown 
into  the  foramen  ovale;  and,  after  having  been  moved  backwards  and 
forwards  between  these  two  points  several  times,  it  was  finally  carried 
directly  from  the  foramen  ovale  into  the  socket  by  manual  extension 
applied  in  the  ordinary  way,  but  without  pulleys.  "  In  this  case,"  says 
Markoe,  "the  cure  was  very  slow,  and  he  left  the  hospital  with  some 
degree  of  pain  and  swelling  about  the  joint.  I  learned  that  an  abscess 
formed  in  or  about  the  joint,  which  was  opened,  and  when  I  saw  him, 
a  year  after,  there  was  every  appearance  of  seated  morbus  coxarius." 

In  Case  14,  of  Markoe's  paper,  the  thigh  was  broken  at  the  neck 
after  manipulation  had  been  employed,  but  while  extension  was  being 
made  by  the  hands,  united  with  "  a  lifting  outwards."     Whether  the 

'  Buffalo  Medical  Journal,  vol.  xiii.  p.  682. 


65-i  DISLOCATIONS    OF    THE    THIGH. 

fracture  was  due  to  the  extension,  or  to  the  manipulation,  seems  not 
to  be  clearly  determined.  The  dislocation  had  existed  seven  weeks 
when  this  attempt  at  reduction  was  made. 

Dr.  Bigelow  has  reported  a  case  of  dislocation  upon  the  dorsum, 
of  six  months'  standing,  in  a  man  23  years  of  age,  which  he  attempted 
to  reduce  and  caused  a  fracture  of  the  neck  of  the  femur.  His  ac- 
count of  the  manner  in  which  the  accident  occurred  is  as  follows :  "  I 
flexed  the  limb  once  slowly  upward  upon  the  abdomen — a  movement 
which  was  attended  with  a  continued  fine  crepitation  about  the  hip." 
Upon  examination,  the  head  of  the  bone  was  found  to  be  separated 
from  the  neck. 

Assisted  by  my  pupil,  Mr.  Hodge,  I  have  also  succeeded  in  collect- 
ing sixty-two  cases  of  attempts  at  reduction  by  extension ;  a  great 
majority  of  which,  we  find,  were  reduced  in  the  first  trials ;  but  five 
cases  of  recent  dislocation  were  not  reduced  until  after  several  attempts 
had  been  made. 

In  five  cases  the  femur  was  broken.  The  first  occurred  in  St. 
Thomas's  Hospital,  London.  Ben.  Whittenburg,  get.  40,  was  admitted 
Nov.  4  1827,  with  a  dislocation  into  the  ischiatic  notch,  of  twenty-two 
weeks'  duration.  After  bleeding,  &c.,  had  been  practised,  an  attempt 
was  made  to  reduce  the  bone  by  pulleys,  in  which  the  reporter  pro- 
fesses to  believe  they  were  successful,  but  on  the  following  day  it  was 
plainly  enough  not  in  place.  Mr.  Travers  again  resorted  to  extension, 
and  while  extension  was  kept  up  and  the  assistants  were  rotating  the 
limb  outwards,  the  neck  of  the  femur  gave  way.*  Malgaigne  mentions 
a  case  in  which,  while  he  was  himself  directing  the  operation,  the  thigh 
was  broken  through  its  lower  third.  He  was  attempting  to  reduce  the 
bone  by  extension,  but  it  was  not  until  he  gave  the  signal  for  rotation 
outwards  that  the  bone  gave  way.^  Gibson  says  that  Dr.  Physick,  at 
the  Pennsylvania  Hospital,  while  engaged  in  reducing  a  dislocated 
thigh  by  the  pulleys,  broke  the  femur  in  consequence  of  exerting  too 
much  force  upon  it  in  a  lateral  direction  by  an  additional  pulley;  and 
that  a  similar  accident  is  supposed  to  have  happened  to  Drs.  Plarris 
and  Eandolph  in  the  same  hospital,  in  the  year  1838,  while  using  the 
pulleys  upon  a  boy  twelve  years  of  age ;  for  during  extension  and 
counter-extension,  at  the  moment  of  rotating  the  limb,  and  of  drawing 
it  forcibly  outwards  by  a  towel,  a  sudden  crack  was  heard.' 

The  fifth  case  is  related  by  Sir  Astley  Cooper  as  having  occurred 
at  the  Brighton  Hospital,  under  the  care  of  Mr.  Gwynne ;  the  dislo- 
cation was  upon  the  dorsum  ilii,  and  was  supposed  to  have  existed 
about  one  month.  The  neck  of  the  femur  was  broken  in  the  first  at- 
tempt at  reduction,  and  while  the  surgeon  was  making  extension,  with 
gentle  rotation.* 

Sir  Astley  says :  "  There  are  plenty  of  cases  upon  record,  of  fatal 
abscesses  from  violent  attempts  at  the  reduction  of  dislocated  hips." 
We  presume  that  this  remark  has  reference  to  attempts  at  reduction 

>  London  Med.-Chir.  Rev._,  Nov.  1828,  p.  239. 

2  Malgaigne,  op.  cit.,  vol.  ii.  pp.  146  and  830. 

3  Gibson's  Surgery,  sixth  ed.,  vol.  i.  p.  389. 

*  Sir  Astley  Cooper  on  Disloc,  &c.,  Amer.  ed.,  p.  88. 


UPWAEDS    AXD    BACKWARDS    OX    THE    DORSUM    ILII.      655 

Tdj  extension,  since,  in  his  day,  this  was  almost  the  only  mode  in  use 
among  surgeons.  He  adds,  moreover,  that  Mr.  Skey  has  mentioned, 
in  the  Lancet,^  a  fatal  case  of  phlebitis  following  protracted  extension 
of  the  hip. 

Malgaigne  has  collected  no  less  than  eight  similar  examples,  with 
several  more  in  which  serious  consequences  and  even  death  followed 
promptly  upon  violent  attempts  at  reduction  by  mechanical  means,^ 

The  head  of  the  bone  has  been  repeatedly  thrown  from  the  dorsum 
ilii  into  the  ischiatic  notch,  and  B.  Cooper  mentions  a  case  in  which 
the  bone  was  carried  from  the  foramen  ovale  into  the  ischiatic  notch, 
from  which  latter  position  it  could  not  afterwards  be  changed.^ 

As  to  the  relative  chances  of  failure  by  the  two  methods,  the  testi- 
mony of  the  recorded  cases  is  equally  unsatisfactory.  Of  the  failures 
by  extension,  the  experience  of  almost  every  surgeon,  the  journals,  and 
the  treatises  furnish  a  suflEicient  number  of  examples;  while  among 
the  sixty-four  cases  of  attempts  at  reduction  by  manipulation  collected 
by  me,  and  excepting  the  cases  in  which  the  bone  was  broken,  only 
two  were  positive  failures.  It  is  somewhat  remarkable,  however,  that 
these  two  cases  occurred  in  the  experience  of  the  New  York  City  Hos- 
pital ;  and  that  they  are  taken  from  a  total  of  fifteen,  this  being  the 
whole  number  which  had  been  treated  by  this  method  at  the  date  of 
these  observations,  in  the  New  York  Hospital,  One  had  existed  one 
month,  and,  after  repeated  trials  by  manipulation  and  frequent  changes 
of  position,  it  was  finally  reduced  by  pulleys.  The  other,  a  dislocation 
into  the  ischiatic  notch,  had  existed  only  a  few  hours.  At  least  seven 
or  eight  trials  were  made  to  accomplish  the  reduction  by  manipulation, 
but  without  success.  The  first  attempt  by  extension  failed  also,  but 
in  the  second  attempt  the  femur  was  kept  at  a  right  angle  with  the 
body,  and  the  bone  was  soon  brought  into  its  socket.^ 

We  have  in  these  two  examples  not  only  a  record  of  failure  by 
manipulation,  but  an  equal  record  of  success  by  extension ;  while,  on 
the  other  hand,  we  find  in  an  analysis  of  the  sixty-four  cases,  sixteen 
triumphs  of  manipulation  over  extension. 

"We  must  not  omit  to  mention,  in  order  that  the  reader  may  form 
a  just  estimate  of  the  value  of  these  statistics,  that  the  great  majority, 
especially  of  the  cases  treated  by  manipulation,  have  occurred  in 
private  practice,  and  it  is  unnecessary  to  say  that  such  statistics  do 
not  furnish  the  most  reliable  basis  for  conclusions.  As  a  general  rule, 
unsuccessful  cases  are  not  published  by  private  practitioners,  but  suc- 
cessful cases  are  pretty  certain  to  be  made  known ;  while,  on  the  other 
hand,  a  series  of  cases  furnished  by  any  single  hospital  will  generally 
be  found  to  have  given  both  unsuccessful  and  successful  cases.  The 
writer  has  heard  lately  of  a  complete  failure  to  reduce  by  manipulation 
in  a  recent  luxation  of  the  hip,  after  repeated  efforts  on  several  succes- 
sive days,  and  where  skilful  surgeons  were  in  attendance;  but  it  is 
believed  that  no  account  of  the  result  has  been  published. 

'  Op.  cit.,  vol.  i.  p.  767,  1840-41.     Cooper  on  Disloc,  p.  69. 

2  Malgaigne,  op.  cit.,  vol.  ii.  p.  164  et  seq. 

»  Sir  Astley  Cooper  on  Disloc.     By  Bransby  Cooper,  Amer.  ed.,  p.  90. 

4  Van  Buren,  New  York  Med.  Times,  Jan.' 1856,  p.  120. 


656  DISLOCATIONS    OF    THE    THIGH. 

We  have  already  called  attention  to  the  fact  that,  in  the  New  York 
City  Hospital,  two  of  the  'fifteen  cases  reported  were  failures ;  a  cir- 
cumstance of  remarkable  significance,  especially  when  we  consider  the 
skill  of  the  several  gentlemen  who  were  the  operators  in  these  cases ; 
and  it  plainly  renders  a  new  series  of  statistics  necessary,  drawn  solely 
from  the  experience  of  one  or  more  similar  large  establishments,  before 
we  shall  be  prepared  to  decide  positively  upon  the  relative  value  of 
the  two  procedures. 

Nevertheless,  we  shall  not  hesitate  to  express  our  present  convic- 
tions upon  this  subject,  reserving  to  ourselves  the  right  of  a  change  of 
opinion  whenever  the  proofs  shall  warrant  it. 

Manipulation,  owing  to  the  greater  power  which  may  be  brought 
to  bear  upon  the  neck  and  head  of  the  bone  through  the  action  of  the 
shaft  of  the  femur  as  a  lever,  is  most  liable  to  throw  the  head  of  the 
bone  into  new  positions,  and  consequently  most  liable  to  rupture  the 
various  soft  tissues  about  the  joint,  to  produce  inflammation,  suppura- 
tion, and  caries.  For  the  same  reason  it  is  most  liable,  also,  to  fracture 
the  neck  of  the  femur.  It  is  not  certain  in  our  mind  but  that,  when 
the  principles  which  control  the  reduction  are  more  completely  under- 
stood, these  evils  may  be  lessened ;  yet  we  can  scarcely  persuade  our- 
selves that  by  any  future  observations  the  state  of  the  question  will 
ever  be  greatly  changed.  We  cannot  but  think,  also,  that  some  con- 
clusions ought  to  be  drawn  from  the  circumstances  that,  since  the  time 
of  Hippocrates  to  the  present  day,  manipulation  has  been  occasionally 
recommended  and  successful  examples  reported;  the  reduction  being 
accomplished  in  most  instances  by  processes  identical,  or  nearly  so, 
with  those  now  adopted ;  yet  generally  the  writers  appear  to  have 
been  ignorant  of  what  had  been  done  before,  and,  indeed,  they  have 
generally  avowed  their  belief  that  the  method  suggested  by  themselves 
was  altogether  new  and  original.  Possibly  this  slowness  to  establish, 
and  total  inability  to  sustain  and  perpetuate  a  reputation,  was  not  the 
fault  of  the  method,  and  had  no  relation  to  its  failures.  Until  within 
a  few  years,  the  number  of  surgical  books,  and  especially  of  medical 
journals,  was  comparatively  very  small,  so  that  valuable  truths  often 
died  with  their  discoverers,  or  were  known  and  remembered  only  by 
a  few ;  but  it  is  possible,  also,  that  it  has  a  deeper  significance,  and  that 
it  implies  some  defect  in  the  procedure,  or  serious  danger,  in  conse- 
quence of  which  it  has  from  time  to  time  lapsed  into  desuetude  and 
finally  into  complete  oblivion. 

The  rules  which  the  author  would  give  for  the  employment  of 
manipulation  are  very  simple. 

The  patient  being  laid  on  his  back  upon  a  mattress,  the  surgeon, 
assuming  that  it  is  a  dislocation  upon  the  dorsum  ilii,  should  seize  the 
foot  with  one  hand  and  the  other  he  should  place  under  the  knee ; 
then,  flexing  the  leg  upon  the  thigh,  the  knee  is  to  be  carefully  lifted 
toward  the  face  of  the  patient  until  it  meets  with  some  resistance ;  it 
must  then  be  moved  outwards  and  slightly  rotated  in  the  same  direc- 
tion until  resistance  is  again  encountered,  when  it  must  be  gradually 
brought  downwards  again  to  the  bed.  We  do  not  know  that  the 
whole  process  could  be  expressed  in  simpler  or  more  intelligible  terms. 


UPWARDS    AND    BACKWAEDS    ON    THE    DORSUM    ILII.      657 

than  to  say,  that  the  limb  should  follow  constantly  its  own  inclina- 
tion. 

All  writers  have  united  in  the  necessity  of  flexion  ;  and,  indeed, 
with  very  few  exceptions,  the  advocates  of  extension  have  insisted 
upon  carrying  the  dislocated  limb  more  or  less  across  the  sound  one ; 
or  of  making  the  extension  at  right  angles  with  the  body.  They 
have  also  been  nearly  unanimous  in  their  statements  that  the  thigh 
should  then  be  abducted  and  finally  brought  down.  Nathan  Smith 
has  added  the  injunction  to  rotate  the  shaft  of  the  femur  outwards, 
and  to  press  gently  upon  the  inside  of  the  knee  while  the  thigh  is 
being  flexed  upon  the  body,  so  as  to  compel  the  head  of  the  bone  to 
hug  the  outer  margin  of  the  acetabulum  and  to  prevent  its  falling 
into  the  ischiatic  notch ;  a  suggestion  which  has  been  erroneously  in- 
terpreted by  some  writers  to  mean  that  he  would  carry  up  the  limb 
abducted,  a  thing  which  is  simply  impossible  until  the  reduction  is 
accomplished.  In  adopting  this  practice,  however,  we  must  not  forget 
the  danger  which  we  incur  when  the  limb  is  completely  flexed,  and 
the  head  of  the  femur  is  below  the  edge  of  the  acetabulum,  of  throwing 
it  over  into  the  foramen  ovale.  Dr.  Nathan  Smith  has  also  noticed 
the  advantage  which  sometimes  may  be  gained  by  giving  to  the  limb 
at  this  moment  a  slight  rocking  motion. 

These  movements  of  the  limb,  with  perhaps  other  slight  modifica- 
tions, such  as  lifting  the  knee  moderately  or  forcibly  when  the  bone 
refuses  to  mount  over  the  margin  of  the  acetabulum,  pressing  with 
the  hand  or  foot  upon  the  pelvic  bones,  and  violent  circumduction, 
are  all  which  have  been  usually  practised  in  successful  manipulation. 

We  repeat,  however,  that  as  a  general  rule,  in  the  first  trial,  the 
knee  must  be  carried  only  in  those  directions  which  offer  no  resistance, 
and  these  will  be  found  almost  always  to  be  the  same ;  the  knee  of  the 
dislocated  femur  hanging  over  the  sound  one  will  be  made  easily  to 
ascend  to  about  a  right  angle  with  the  body,  we  can  then  carry  it  out- 
wards a  short  distance,  probably  not  more  than  four  or  five  degrees ; 
at  this  moment,  frequently,  the  thigh  will  begin  to  rotate  outwards  of 
itself,  and  with  considerable  force,  or,  as  Wathman  says,  "  a  self-twist- 
ing of  the  thigh  occurs,  which  cannot  be  prevented  by  fast  holding." 
When  this  action  takes  place,  the  reduction  is  immediately  accom- 
plished ;  and  it  is  in  fact  at  this  moment,  before  the  limb  begins  to 
descend,  that  the  bone  most  frequently  resumes  its  socket.  If  it  does 
not,  then  as  soon  as  the  limb  begins  to  fall  the  reduction  occurs, 
generally  with  a  loud  snap.  It  is  pretty  certain  that  this  manipula- 
tion is  to  fail  if  the  knee  has  descended  more  than  a  few  inches  with- 
out the  reduction  having  taken  place ;  and  it  will  be  better  to  repeat 
the  manoeuvre  at  once,  rather  than  to  bring  the  limb  completely  down. 

Generally  anaesthetics  ought  not  to  be  employed,  since  the  opera- 
tion, if  successful,  is  not  usually  painful,  and  we  need  that  the  patient 
should  preserve  his  consciousness,  in  order  to  admonish  us  when  we 
are  using  improper  violence.  It  is  probable,  also,  that  the  action  of 
certain  muscles  sometimes  aflbrds  material  assistance  in  the  reduction. 
If,  however,  the  patient  is  very  sensitive,  or  the  parts  about  the  joint 


658  DISLOCATIONS    OF    THE    THIGH. 

are  very  tender,  or  manipulation  without  anaesthetics  has  failed,  then 
certainly  these  agents  may  be  properly  and  advantageously  employed. 

If  we  propose  to  attempt  reduction  by  extension,  it  is  no  longer 
necessary  to  resort  to  the  lancet,  antimony,  and  the  hot  bath,  as  pre- 
liminary measures,  since  the  muscles  can  be  at  once  overcome  by  the 
much  more  certain  and  more  powerful  agents,  chloroform,  ether,  &c. 

The  method  recommended  by  Sir  Astley  Cooper,  and  most  often 
practised  by  surgeons  of  the  present  day,  is  essentially  as  follows : — 

The  patient  is  placed  upon  a  bed  of  suitable  height,  reclining  on 
his  back,  but  partly  over  upon  the  sound  side.  Observing  now  the 
line  of  the  axis  of  the  dislocated  thigh,  one  strong  staple  is  to  be 
secured  into  the  wall  upon  one  side  of  the  room,  and  another  upon  the 
opposite  side,  both  of  which  shall  correspond  as  nearly  as  possible 
with  the  line  of  the  shaft  of  the  femur.  The  staple  in  front  of  the 
body  will  be  higher  than  the  bed,  and  the  staple  behind  will  be,  in 
the  same  proportion,  lower  than  the  bed.  The  limb  being  stripped, 
two  pieces  of  strong  factory  cloth,  each  about  four  inches  wide  and 
two  feet  long,  should  be  laid  parallel  with  and  on  each  side  of  the 
limb ;  the  centre  of  each  strip  being  about  opposite  that  portion  of 
the  thigh  which  is  just  above  the  two  condyles.  Over  the  centre  of 
these  strips,  above  the  condyles  and  patella,  a  strong  roller,  three 
inches  wide  and  at  least  three  yards  long,  previously  wetted  in  water, 
is  to  be  turned  as  tightly  as  it  can  be  drawn  until  the  whole  roller  is 
exhausted ;  the  extremity  of  the  roller  being  made  fast  with  a  needle 
and  thread  rather  than  with  pins.  The  upper  ends  of  the  side  strips 
are  then  to  be  brought  down,  and  tied  to  the  lower  ends,  forming 
thus  two  lateral  loops,  upon  which  one  of  the  hooks  of  the  compound 
pulleys  is  to  be  made  fast,  while  the  other  hook  is  secured  to  the  front 
staple  in  the  wall.  Instead  of  these  rollers  we  may  employ,  if  we 
choose,  a  leathern  thigh-belt.  For  the  purpose  of  counter-extension 
a  sheet  is  folded  diagonally,  and  its  centre  being  applied  to  the  peri- 
neum of  the  dislocated  limb,  the  ends  are  tied  firmly  into  the  back 
staple.  To  prevent  the  body  from  moving  laterally,  under  the  action 
of  the  pulleys,  one  assistant  should  be  seated  upon  the  bed,  with  his 
back  against  the  side  and  back  of  the  patient,  and  his  right  arm 
thrown  over  the  body ;  it  is  well  also  to  station  another  beside  the 
sound  limb,  so  as  to  retain  it  also  in  its  place  upon  the  bed.  Under- 
neath the  upper  part  of  the  dislocated  limb  a  strong  and  broad  band- 
age should  be  placed,  of  sufficient  length  to  tie  over  the  neck  of  the 
surgeon  when  he  is  standing  about  half  bent  over  the  body  of  the 
patient. 

Everything  being  arranged,  and  all  portions  of  the  apparatus  having 
been  sufficiently  tested  to  make  sure  that  nothing  will  give  way  during 
the  operation,  the  anaesthetic  is  to  be  administered,  and  as  the  patient 
falls  gradually  under  its  influence,  the  action  of  the  pulleys  should 
commence,  and  be  slowly  but  steadily  increased;  a  third  assistant 
managing  the  rope,  so  as  to  leave  the  surgeon  unembarrassed,  and 
able  to  direct  his  whole  attention  to  the  position  of  the  trochanter 
major  and  of  the  head  of  the  femur.     In  order  to  this,  he  should 


UPWARDS    AND    BACKWARDS    ON"    THE    DORSUM    ILII.      659 

place  one  hand  upon  each  of  these  prominences,  and  watch  carefully 
their  descent. 

The  length  of  time  which  will  be  required  to  bring  down  the  limb 
must  difl'er  greatly  in  different  persons,  according  to  the  peculiar  cir- 
cumstances of  the  case,  and  the  condition,  age,  &c.,  of  the  patient;  but 
it  must  never  be  forgotten  that  a  slow  and  steady  action  is  much  more 
effective  than  rapid  and  irregular  tractions,  and  it  is  in  this  especially, 
rather  than  in  the  relative  amount  of  power,  that  the  pulleys  possess 
always  so  great  an  advantage  over  the  hands. 

"When  the  surgeon  finds  that  the  head  of  the  bone  has  nearly  or 
quite  reached  the  socket,  if  it  does  not  take  its  place  spontaneously, 
hp  may  place  his  neck  in  the  noose  which  passes  underneath  the  thigh, 
and  lift  upwards  and  outwards,  in  order  to  raise  the  trochanter  major, 
and  thus  enable  the  head  to  rotate  toward  the  acetabulum.  It  is  in 
this  part  of  the  manoeuvre,  and  especially  when  at  the  same  moment 
one  of  the  assistants,  after  bending  the  leg  upon  the  thigh  so  as  to 
make  of  it  a  lever,  has  rotated  the  thigh  outwards,  that  the  fracture 
of  the  neck  has  generally  taken  place ;  and  we  cannot  be  too  cautious, 
therefore,  particularly  in  old  persons,  not  to  bear  very  strongly  upon 
the  noose,  nor  to  permit  the  assistant  to  rotate  outwards  with  great 
force. 

If  the  bone  does  not  enter  the  socket,  we  may  increase  the  flexion, 
or  suddenly  release  the  tension,  or,  in  fine,  again  resort  to  manipula- 
tion alone. 

When  the  reduction  is  accomplished,  the  patient  should  be  laid 
upon  his  back,  with  the  knees  resting  over  a  pillow,  and  tied  together 
lightly  with  a  towel  or  a  strip  of  cotton  cloth.  In  order  also  the  more 
certainly  to  prevent  a  reluxation,  the  thigh  of  the  dislocated  limb 
should  be  gently  rotated  outwards,  by  which  the  head  will  be  pressed 
forwards  against  the  anterior  portion  of  the  capsule. 

Such  an  accident,  however,  as  a  recurrence  of  the  dislocation,  in 
the  case  of  the  femur,  is  exceedingly  rare ;  and  I  should  have  deemed 
it  altogether  impossible,  except  as  the  result  of  considerable  violence 
again  applied,  had  not  at  least  two  examples  been  reported  to  us 
upon  very  excellent  authority.  Malgaigne  says  he  has  himself  seen 
an  example  of  reluxation  upon  the  dorsum  ilii,  occasioned  by  an  un- 
timely movement  ;^  and  Verneuil  has  seen,  ten  days  after  the  reduc- 
tion of  a  dislocation  upon  the  ischiatic  notch,  the  dislocation  repro- 
duced by  a  sudden  effort  of  the  patient  to  sit  up  f  indeed,  it  is  when 
the  limb  is  in. a  flexed  position  that  the  accident  seems  most  likely  to 
occur. 

Of  course,  in  these  remarks  we  mean  to  except  those  cases  in  which 
the  upper  margin  of  the  acetabulum  is  broken  off,  and  the  head  of  the 
femur  has  consequently  lost  its  natural  support  in  this  direction. 

The  possibility  of  this  accident  is  also  confirmed  by  the  examples 
of  '•■  voluntary"  dislocations  which  I  shall  relate  in  the  last  section  of 
this  chapter. 

'  Malgaigne,  op.  cit.,  torn.  ii.  p.  830.  2  dm.,  p.  8i0. 


660 


DISLOCATIONS    OF    THE    THIGH, 


The  method  of  extension  recommended  by  Dr.  Bigelow,  namely, 
with  the  thigh  at  a  right  angle  with  the  body,  has  already  been  referred 
to ;  and  there  is  much  reason  to  believe  that,  as  a  rule,  it  is  preferable 
to  extension  as  practised  by  Sir  Astley  Cooper.  Nearly  all  surgeons, 
bowever,  have  recognized  the  necessity  of  flexing  the  thigh  in  certain 

cases.     Dr.  Bigelow  sug- 
'  Fig.  285.  gests  that  where  greater 

force  is  required  than  can 
be  obtained  by  the  usual 
methods,  a  tripod  should 
be  employed,  as  shown  in 
the  accompanying  wood- 
cut. 

The  following  case,  re- 
ported to  me  by  Dr.  N. 
Fanning,  of  Catskill,  N.Y., 
illustrates  the  occasional 
necessity  of  resorting  to 
extension,  and  is  of  special 
interest  on  account  of  the 
extreme  youth  of  the  pa- 
tient. I  have  referred  to 
the  same  case  once  before. 
A  little  girl,  two  and  a 
half  years  old,  was  caught 
under  a  falling  door  on 
the  24th  of  May,  1867, 
but  her  parents  suspected 
no  injury  beyond  a  severe 
bruise  until  ten  days  later, 
when  they  consulted  Dr. 
Fanning.  The  left  femur 
was  then  found  to  be  dislocated  upon  the  dorsum  ilii.  Dr.  Fanning 
attempted  first  to  reduce  the  dislocation  by  manipulation,  but  he  failed. 
He  then  directed  the  father  to  make  extension  by  the  legs,  while  the 
mother  made  counter-extension  by  seizing  the  child  under  the  arms, 
and  thus  he  soon  succeeded  in  effectino:  the  reduction. 


Tripod  for  vertical  extension.    (Bigelow.) 


§  2.  Dislocations  Upwards  and  Backwards  into  the  Great  Ischiatic 

Notch. 

iSyn. — "  Upwards  and  backwards  into  the  ischiatic  notch  ;"  Sir  A.  Cooper.  "Up- 
wards and  backwards  into  the  great  sacro-sciatic  notch;"  Lizars.  "Backwards 
into  the  sacro-sciatic  foramen  ;"  S.  Cooper.  "Backwards  into  tlie  ischiatic  notch ;" 
Listou,  B.  Cooper,  Miller,  Pirrie,  Erichsen,  Skey,  Gibson.  "Downwards  and  out- 
wards on  the  OS  ischium;"  Boyer,  Dorsey.  "Backwards  and  downwards  into 
the  ischiatic  notch  ;"  Chelius,  Petit,  Duverney.  "Upon  the  ischium  ;"  Bertrandi. 
"Sacro-sciatic;"  Gerdy.  "Ischiatic;"  Malgaigne.  "Dorsal  below  the  tendon;" 
Bigelow. 

Boyer  considers  this  dislocation  as  only  secondary  upon  a  disloca- 
tion upon  the  dorsum  ilii ;  but  it  is  very  certain  that  it  often  occurs 
as  a  primary  accident.    Not  unfrequently,  also,  what  was  primarily  a 


UPWARDS    AND    BACKWARDS    INTO    ISCHIATIC    NOTCH.      661 

dislocation  into  the  iscbiatic  notch,  becomes  subsequently  a  dislocation 
upon  the  dorsum  ilii.  -,.    ,    . 

Causes. A  fall  upon  the  foot  or  knee  when  the  limb  is  very  much 

in  advance  of  the  body ;  or  -the  fall  of  a  heavy  weight  upon  the  back 


Fio-.  286. 


Fii?.  287. 


Dislocation  upwards  and  backwards 
into  the  great  iscliiatic  notch.  (A. 
Cooper.) 

and  pelvis  when  the  thigh 
is  nearly  or  quite  at  a  right 
angle  with  the  body.  In- 
deed, the  causes  are  very 
similar  to  those  which  pro- 
duce dislocations  upon  the 
dorsum  ilii,  except  that  it 
is  necessary  to  suppose  the 
limb  in  a  position  more 
nearly  at  a  right  angle  with 
the  trunk,  at  the  moment  in 
which  the  force  is  applied. 

Pathological  Anatomy.— Mr.  Syme,  who  dissected  the  body  of  a 
man  recently  dead  whose  thigh  had  been  dislocated  into  the  ischiatic 
notch,  found  the  gluta3us  maximus  nearly  torn  asunder,  the  head  of 
the  femur  being  imbedded  in  its  substance;  the  glutseus  minimus, 
the  pyriformis,andthe  gemellus  superior  lacerated;  the  capsular  liga- 
ment extensively  torn  close  to  the  edge  of  the  acetabulum,  and  the 
round  ligament  "completely  separated  from  the  femur.  The  head  of 
the  femur  was  lying  in  the  great  ischiatic  notch,  upon  the  gemelli 
and  the  sacro-sciatic  nerve,  behind  the  acetabulum  and  a  little  above 


Dislocation  upwards  and  bacliwards,  into  the  great  ischi- 
atic notch. 


662  DISLOCATIONS    OF    THE    THIGH. 

it ;  being  situated  between  the  upper  margin  of  the  notch  and  the 
great  sacro-sciatic  ligaments.^  Figure  286  is  a  representation  of  this 
specimen. 

Dr.  Joseph  C.  Hutchinson,  of  Brooklyn,  N.  Y.,  has  reported  an  ex- 
ample of  this  dislocation  in  which  death  having  occurred  four  days 
after  reduction,  he  was  able  to  ascertain  the  character  of  the  lesions. 
By  the  courtesy  of  Dr.  H.,  I  was  permitted  to  be  present  at  this 
autopsy,  and  the  lesions^were  found  to  be  much  the  same  as  in  the 
case  related  by  Syme ;  but  the  glutseus  minimus  was  not  torn,  and 
there  was  added  a  laceration  of  the  obturator  externus.  Dr.  Lente 
has  reported  one  other  dissection  made  after  reduction.^ 

Dr.  Bigelow  speaks  of  a  dorsal  dislocation  as  sometimes  occupying  a 
position  as  low  a;s  the  upper  portion  of  the  ischiatic  notch ;  but  the 
dislocation  now  under  consideration  he  describes  as  that  in  which  the 
head  of  the  femur  having  been  driven  from  its  socket  downwards  and 
backwards,  is  subsequently,  in  the  attempt  to  straighten  the  limb, 
carried  upwards  behind  the  socket  until  it  is  arrested  by  the  strong 
tendon  of  the  obturator  internus,  and  the  subjacent  capsule.     In  some 

Fig.  288. 


Internal  obturator  in  its  natural  position.     (Bigelow.) 

cases  also  the  head  passes  behind  the  tendon  and  the  subjacent  cap- 
sule. He  prefers,  therefore,  to  speak  of  this  dislocation  as  "dorsal 
below  the  tendon." 

Symptoms. — The  position  of  the  limb  is  in  some  cases  nearly  the 

1  Amer.  Joum.  Med.  Sci.,  vol.  xxxii.  p.  460. 

2  Lente,  New  York  Journ.  Med.,  Jan.  1851. 


UPWARDS    AND    BACKWARDS    INTO    ISCHIATIC    NOTCH.      663 


same  as  in  certain  dislocations   upon  the  dorsum.     It  is  shortened 
usually  about  half  an  inch,  the  thigh  being  flexed  upon  the  body, 

Fig.  289. 


Ficr.  290. 


Internal  obturator  in  its  new  position.     (Bigelow.) 

adducted,  and  rotated  inwards;  but  the  flexion  is  often  less  than  in 
dislocations  upon  the  dorsum,  while,  on  the  other  hand,  it  is  sometimes 
much  greater.  Generally  it  is  such  that,  when  the  patient  is  standing, 
the  end  of  the  great  toe  of  the  dislocated  limb  touches  the  ball  of  the 
great  toe  of  the  sound  limb. 

Bigelow  observes  that  the  extreme 
flexion  which  is  sometimes  found 
to  exist,  especially  when  the  patient 
is  in  the  recumbent  position,  is 
generally  due  to  the  arrest  of  the 
head  of  the  femur  by  the  internal 
obturator  and  the  subjacent  untorn 
capsule.  When  the  patient  rises,  the 
weight  of  the  limb  may  force  the 
head  up  behind  the  tendon  of  the 
obturator;  or  if  the  limb  is  brought 
down  with  force,  the  tendon  and 
capsule  may  give  way  and  the  head 
may  ascend  to  any  point  upon  the 
outer  surface  of  the  ilium,  and  in 

this   way    an    ischiatic    may    be    con-  Dislocation  upwards  and  backwards  into  the 

verted  into  an  iliac  dislocation.  great  ischiatic    notch.    "Below  the    tendon," 

when  the  patient  is  recumbent.    (Bigelow.) 


I 


664  DISLOCATIONS    OF    THE    THIGH. 

The  head  of  the  femur  is  sometimes  distinctly  felt  in  its  new  position, 
especially  when  the  limb  is  moved  upwards  or  downvvards.  The  tro- 
chanter major  is  approximated  toward  the  anterior  superior  spinous 
process  of  the  ilium. 

Sir  Astley  Cooper  remarks  that  this  dislocation  is  the  most  difficult 
to  detect,  and  Mr.  Syme  mentions  a  case  in  which  the  nature  of  the 
accident  was  overlooked  by  himself,  and  the  thigh  was  not  reduced 
until  the  thirteenth  day/  and  subsequently  Mr.  Syme  has  called  at- 
tention to  what  he  considers  as  one  of  the  most  important  diagnostic 
marks — indeed,  he  says  it  is  never  absent,  nor  is  it  ever  met  with  in 
any  other  injury  of  the  hip-joint,  "whether  dislocation,  fracture,  or 
bruise ;"  this  is  "  an  arched  form  of  the  lumbar  part  of  the  spine,  which 
cannot  be  straightened  so  long  as  the  thigh  is  straight,  or  on  a  line 
with  the  patient's  trunk.  When  the  limb  is  raised  or  bent  upwards 
upon  the  pelvis,  the  back  rests  flat  upon  the  bed ;  but  so  soon  as  the 
limb  is  allowed  to  descend,  the  back  becomes  arched  as  before."^  This 
position,  assumed  by  the  back  when  an  attempt  is  made  to  straighten 
and  depress  the  limb,  is  due  to  the  action  of  the  psoas  magnus  and 
iliacus  internus.  But,  in  addition  to  this  valuable  sign,  the  inversion 
of  the  toes,  immobility  of  the  limb,  and  the  absence  of  crepitus,  are 
generally  sufficient  in  themselves  to  distinguish  it  from  a  fracture  of 
the  neck.  Dr.  Squires,  of  Elmira,  N.  Y.,  in  a  note  addressed  to  me  in 
March,  1860,  suggests,  also,  that  in  ancient  cases  the  projection  of  the 
head  of  the  femur  may  be  felt  by  passing  the  finger  into  the  rectum 
or  vagina.  In  this  way  Dr.  Sayre  and  myself  determined  a  dislocation 
into  the  ischiatic  notch  which  had  existed  six  months,  in  a  boy  twelve 
years  old ;  and  Dr.Wood,  with  myself,  diagnosticated  the  same  dis- 
location in  a  woman  at  Bellevue  Hospital,  which  had  existed  four 
weeks,  in  the  same  manner. 

Prognosis. — I  have  seen  two  dislocations  of  this  character  which 
were  not  recognized  by  the  surgeons  at  the  time  of  the  receipt  of  the 
injury,  nor  for  some  weeks  afterwards.  One  was  in  a  lad  twelve  years 
old,  who  was  brought  to  me  from  an  adjacent  county  in  August,  1847. 
The  accident  had  happened  eight  weeks  before.  His  limb  was  short- 
ened one  inch;  it  was  also  forcibly  adducted  and  rotated  inwards. 
Dr.  Colegrove,  a  very  excellent  surgeon,  had  made  a  thorough  attempt 
to  reduce  the  dislocation  with  pulleys  a  few  days  before  he  was  brought 
to  me,  and  I  did  not  deem  it  advisable  to  subject  him  again  to  the  trial. 
Notwithstanding  the  dislocation,  his  limb  was  quite  useful.  The  second 
was  in  the  case  of  the  boy  seen  by  Dr.  Sayre  and  myself,  to  which  I 
have  just  referred. 

Treatment. — In  employing  manipulation,  we  may  follow,  with  only 
a  slight  modification,  the  directions  already  given  in  dislocations  upon 
the  dorsum  ilii.  We  find  the  head  of  the  femur  lower,  consequently 
the  extent  of  the  circuit  to  be  described  in  the  manoeuvre  is  diminished, 
but  in  other  respects  the  processes  are  identical. 

'  Amer.  Joum.  Med  Sci.,  vol.  xviii.  p.  242. 

2  Amer.  Journ.  of  Med.  Sci.,  Oct.  1843,  p,  461,  from  Lond.  and  Edinb.  Month. 
Journ.,  July,  1843. 


UPWARDS    AND    BACKWARDS    INTO    ISCHIATIC    NOTCH.      665 

"We  must  not  forget,  however,  that  there  is  especial  danger,  while 
attempting  to  reduce  this  dislocation  by  manipulation,  that  the  head 
of  the  bone  will  be  thrown  across  into  the  foramen  thyroideum.  I 
have  already  mentioned  one  case  occurring  under  the  care  of  Dr.  Post 
in  the  New  York  Hospital,  in  which  the  head  of  the  femur,  originally 
in  the  ischiatic  notch,  passed  backwards  and  forwards  between  the 
ischiatic  notch  and  the  foramen  ovale  many  times,  and  which,  although 
the  reduction  was  finally  accomplished,  was  followed  by  morbus  coxa- 
rius.  Parker  mentions  a  second  case  in  the  same  paper,'  in  which  his 
first  attempt  to  reduce  by  manipulation  carried  the  head  of  the  bone 
into  the  foramen  ovale ;  but  the  second  attempt  was  successful.  In 
Dr.  Hutchinson's  case,  to  which  I  have  already  referred,  the  first 
attempt  at  reduction  was  made  without  an  anaesthetic,  and  by  manipu- 
lation after  the  method  described  by  Reid.  The  first  two  attempts 
failed,  and  in  the  third,  the  limb  being  more  abducted  than  before,  the 
head  of  the  bone  was  thrown  into  the  foramen  ovale.  By  reversing 
the  movements,  it  was  replaced  in  the  ischiatic  notch  ;  and  this  change 
of  position  was  made  seven  or  eight  times.  The  patient  was  now 
etherized,  and  the  bone  was  lifted  into  its  socket  in  the  same  manner 
which  I  have  described  in  the  case  of  Caswell.  Malgaigne  refers  to  a 
patient  of  Lenoir's  and  to  another  of  his  own,  in  which  the  head  of 
the  bone  was  lodged  under  the  margin  of  the  acetabulum  during  the 
attempts  at  reduction.^ 

On  the  23d  of  March,  1855,  Charles  McCormick,  a3t.  21,  a  laborer  on 
the  "State  Line  Eailroad,"  was  caught  between  two  cars,  with  his  back 
resting  against  one  car,  and  his  right  knee  against  the  other,  the  right 
thigh  being  raised  to  a  right  angle  with  his  body.  As  the  cars  came 
together  he  felt  a  "  cracking"  at  his  hip-joint,  and  found  himself  im- 
mediately unable  to  walk  or  stand. 

Two  hours  after  the  accident,  assisted  by  my  son  Theodore,  and 
Austin  Flint,  Jr.,  I  examined  the  limb  carefully,  and  made  arrange- 
ments for  the  reduction  with  the  pulleys,  in  case  the  attempt  by  ma- 
nipulation should  fail. 

The  patient  lying  upon  his  back,  I  seized  the  right  leg  and  thigh 
with  my  hands,  the  leg  being  moderately  flexed  upon  the  thigh,  and 
carried  the  knee  slowly  up  toward  the  belly,  until  it  had  approached 
within  twelve  or  fifteen  inches,  when,  noticing  a  slight  resistance  to 
farther  progress  in  this  direction,  I  carried  the  knee  across  the  body 
outwards,  until  I  again  encountered  a  slight  resistance,  and  immediately 
I  began  to  allow  the  limb  to  descend.  At  this  moment  a  sudden  slip 
or  snap  occurred  near  the  joint,  and  I  supposed  reduction  was  accom- 
plished;  but  on  bringing  the  limb  down  completely,  I  found  it  was 
still  in  the  ischiatic  notch.  I  think  the  head  had  slipped  off"  from  the 
lower  lip  of  the  acetabulum,  after  having  been  gradually  lifted  upon  it. 

Without  delay  I  commenced  to  repeat  the  manipulation,  and  in 
precisely  the  same  manner.  Again,  at  the  same  point,  when  the  limb 
was  just  beginning  to  descend,  a  much  more  distinct  sensation  of  slip- 

i  Markoe's  paper,  N.  Y.  Journ.  of  Med.,  Jan.  1855. 
2  Malgaigne,  op.  cit.,  torn.  ii.  p.  839. 
43 


666 


DISLOCATIONS    OF    THE    THIGH. 


ping  was  felt,  and  on  dropping  the  limb  it  was  found  to  be  in  place 
and  in  form,  with  all  its  mobility  completely  restored. 

No  anaesthetic  was  employed,  and  no  person  supported  the  body  or 
interfered  in  any  way  to  assist  in  the  redaction.  No  outcry  was  made 
by  the  patient,  yet  he  informed  me  that  the  manipulation  hurt  him 
considerably.  The  amount  of  force  employed  by  myself  was  just 
sufficient  to  lift  the  limb,  and  the  time  occupied  in  the  whole  pro- 
cedure was  only  a  few  seconds. 

Y'ls.  391. 


Reduction  of  dislocation  upwards  and  backwards  into  the  great  ischiatic  notch,  by  extension.    (Sir 
Astley  Cooper's  method.) 

After  the  reduction  he  remained  upon  his  back,  in  bed,  eleven  days, 
in  pursuance  of  my  instructions.  At  the  end  of  this  time  he  began  to 
walk  about,  but  was  unable  to  resume  work  until  after  eight  weeks 
or  more.  It  is  probable  that  he  could  have  walked  immediately  after 
the  reduction,  without  much  if  any  inconvenience,  so  trivial  was  the 
inflammation  which  resulted  from  the  accident.  He  never  complained 
of  pain,  but  only  of  a  slight  soreness  back  of  the  trochanter  major, 
near  the  head  of  the  bone.  This  soreness  continued  several  weeks, 
and  was  especially  present  when  he  bent  forwards.  After  the  lapse 
of  four  months,  when  I  last  saw  him,  he  occasionally  felt  a  pain  at 
this  point  in  stooping,  but  the  motions  of  the  joint  were  free ;  he  walked 
rapidly  and  without  halt. 

If  the  reduction  is  attempted  by  extension,  we  ought  to  remember 
that  the  head  of  the  bone  lies  more  behind  than  above  the  socket,  and 
that  it  is  not  requisite  to  carry  it  downwards  so  much  as  forwards; 


UPWARDS    AND    BACKVrARDS    IXTO    ISCHIATIC    NOTCH.      667 

and  especially"  that  it  must  mount  over  the  most  elevated  margin  of 
the  socket,  in  order  to  resume  its  position.  The  extension  ought, 
therefore,  to  be  made  at  a  right  angle  with  the  body,  as  the  following 
case  will  illustrate: — 

John  Hebden,  a3t.  40,  was  sitting  with  his  legs  hanging  over  the 
dock,  when  his  left  knee  was  struck  by  a  ferry-boat,  dislocating  the 
head  of  the  femur  into  the  ischiatic  notch.  I  found  him  at  Bellevue 
Hospital  on  the  following  morning,  about  twenty  hours  after  the  acci- 
dent, Sept.  29,  1866.  In  the  recumbent  posture  the  limb  was  pretty 
strongly  adducted  and  slightly  rotated  inwards.  It  was  shortened 
three-quarters  of  an  inch.  In  the  erect  posture  both  adduction  and 
inward  rotation  were  very  slight. 

Having  etherized  him,  I  made  three  separate  attempts  at  reduction, 
by  manipulation,  but  failed.  I  then  made  extension  in  the  following 
manner:  The  patient  resting  upon  his  back,  I  stood  astride  his  body, 
and  clasping  my  hands  under  the  knee,  I  pulled  directly  upwards, 
while  an  assistant  held  down  the  pelvis.  I  did  not  feel  the  bone  re- 
sume its  place,  nor  was  I  aware  that  reduction  was  accomplished,  but 
when  I  let  the  limb  down  the  bone  was  found  to  be  in  its  socket. 

Two  or  three  minutes  later,  and  before  the  patient  had  recovered 
from  the  effects  of  the  ether,  I  raised  the  knee,  to  indicate  to  some 
young  men,  who  had  just  come  in,  how  the  dislocation  had  been  re- 
duced, when  it  slipped  out  again,  with  a  sudden  jerk  and  a  grating 
sensation.  This  sensation  I  had  felt  once  or  twice  before  while  ma- 
nipulating. It  was  scarcely  as  rough  as  the  crepitus  of  a  fracture,  and 
it  probably  indicated  that  the  cartilaginous  margin  of  the  acetabulum 
had  been  broken  off. 

The  limb  was  now  brought  down  to  the  bed,  and  it  was  found  to  be 
in  the  same  position  as  before  reduction  was  attempted.  Standing 
again  over  the  patient,  and  placing  my  hands  under  the  knee,  I  pulled 
upwards,  and  the  head  resumed  its  place;  this  time  with  a  sudden 
jerk  and  with  the  same  rough  sensation.  The  limb  was  then  placed 
in  the  extended  position  and  secured  by  a  long  splint,  which  was  not 
removed  until  the  eleventh  day. 

The  facility  with  which  the  reluxation  took  place  in  the  preceding 
case  will  sufficiently  explain  what  happened  in  the  following  case  on 
tlie  tenth  day  after  reduction,  and  on  account  of  which  I  was  subse- 
quently consulted. 

A¥m.  Milne,  xt.  19,  of  Orleans  Co.,  N.  Y.,  was  thrown  from  a  wagon, 
May  13,  1858,  dislocating  his  left  femur  into  the  ischiatic  notch.  Dr. 
Watson,  of  Clarendon,  Orleans  Co.,  was  consulted  within  three  hours. 
Drs.  Wood  and  Tafft  were  also  present.  Dr.  Watson  laid  the  patient 
on  his  back,  and  without  anaesthetics  reduced  the  dislocation  by  ma- 
nipulation. The  bone  was  felt  distinctly  as  it  slipped  into  its  place, 
and  the  limb  immediately  resumed  its  natural  position  and  length,  as 
all  the  surgeons  present  affirm.  He  was  soon  out  of  the  house  on 
crutches,  and  on  the  eleventh  day  went  in  bathing.  When  he  came 
out  of  the  water  he  complained  of  his  hip,  and  on  the  following  day  it 
was  seen  to  be  shortened.  Subsequently  it  was  examined  by  several 
surgeons,  all  of  whom  pronounced  it  dislocated.    An  attempt  was  then 


668  DISLOCATIONS    OF    THE    THIGH. 

made  to  reduce  the  dislocation  by  Jarvis's  adjuster,  but  without  anaes- 
thesia, as  the  patient  refused  to  be  rendered  insensible.  The  attempt 
did  not  succeed,  and  the  father  brought  an  action  against  Dr.  Watson 
in  the  Supreme  Court  of  Orleans  Co.,  Judge  Davis  presiding,  for  Sept. 
1858.  The  prosecutor  failed  to  appear,  and  Dr.  Watson,  the  defend- 
ant, took  judgment  by  default. 

Lente  relates  a  case  in  which,  extension  being  employed,  the  cord 
was  suddenly  cut  while  the  limb  was  abducted  and  rotated  outwards, 
Avhen  the  head  of  the  femur  left  the  ischiatic  notch,  and  rose  upon  the 
dorsum  ilii,  assuming  a  position  directly  above  the  acetabulum,  and 
below  the  anterior  superior  spinous  process ;  and  from  which  position 
it  was  subsequently,  with  great  difficulty,  returned  to  the  socket.^ 

§  3.  Dislocations  Downwards  and  Forwards  into  the  Foramen 

Thyroideum. 

Syn. — "Downwards  into  the  foramen  ovale;"  Sir  A.  Cooper.  "Downwards 
into  the  obturator  foramen;"  Lizars.  "  Downwards  and  forwards  into  the  fora- 
men obturatorium  ;"  B.  Cooper.  "InAvards  and  downwards  into  the  oval  hole  ;" 
Chelius.  "  Downwards  and  forwards  into  the  foramen  ovale  ;"  Pirrie.  "  Down- 
wards and  inwards  ;"  Boyer.  "Sub-pubic;"  Gerdy.  " Ischio-pubic  ;"  Mal- 
gaigne. 

Causes. — In  order  to  produce  this  dislocation  the  limb  must  be,  at 
the  moment  of  the  receipt  of  the  injury,  in  a  position  of  abduction. 
Perhaps  most  often  it  is  occasioned  by  the  fall  of  a  heavy  weight  upon 
the  back  of  the  pelvis  when  the  body  is  bent  and  the  thighs  spread 
asunder. 

Pathological  Anatomy. — The  capsule  gives  way  upon  the  inner  side 
especially;  the  round  ligament  is  torn  from  its  attachment,  and  the 
head  of  the  femur  pressing  forwards  and  downwards,  finds  a  lodge- 
ment upon  the  obturator  externus  muscle,  over  the  foramen  thyroi- 
deum. 

Sym2')toms. — The  thigh  is  lengthened  from  one  to  two  inches,  ab- 
ducted and  flexed,  the  body  being  also  bent  forwards  or  flexed  upon 
the  thigh.  The  dislocated  limb  is  advanced  before  the  other,  and  the 
toes  generally  point  directly  forwards,  but  they  may  incline  either 
outwards  or  inwards.  The  hip  is  flattened  or  depressed ;  the  long 
adductors  are  felt  tense  upon  the  inside  of  the  limb ;  the  trochanter 
major  is  less  prominent  than  upon  the  opposite  side ;  and  the  head  of 
the  bone  may  sometimes  be  felt  in  its  new  position.  The  lengthening 
of  the  limb  alone  is  sufficient  to  distinguish  this  accident  from  a 
fracture  of  the  neck. 

The  flexion  and  abduction  are  due  in  some  measure  to  the  tension 
of  the  psoas  magnus  and  iliacus  internus,  and  perhaps  to  a  similar 
condition  of  other  rotators  and  flexors;  but,  according  to  Bigelow,  the 
ilio-femoral  ligament  offers  the  chief  resistance,  and  constitutes  the 
chief  impediment  to  the  restoration  of  the  bone. 

Treatment. — It  is  pretty  certain  that  in  the  following  example  there 
was  a  spontaneous  reduction,  or  rather,  I  ought  to  say,  an  accidental 

'  Lente,  New  York  Jouru.  Med.,  Nov.  1850,  p.  314. 


IXTO    THE    FORAMEN    THYROIDEUM. 


669 


reduction  of  a  dislocated  femur  from  the  thyroid  foramen.  Perhaps 
it  was  only  an  example  of  a  partial  luxation ;  of  which  species  of  for- 
ward luxation  I  shall  hereafter  relate  another  case  as  having  come 
under  my  own  notice. 

Jacob  Lower,  ast.  10,  fell  from  a  tree,  a  height  of  about  twelve  feet 
to  the  ground.     It  is  not  known  how  he  struck.     He  became  imme- 


Fia;.  293. 


Fio;.  293. 


Relatious  of  the  ilio-femorai  ligament  to  the  thyroid 
dislocation.     (From  Bigelow.) 

diately  quite  faint,  and  when  he  had 
partly  recovered,  he  attempted  to  get 
up,  but  could  not.  He  said  his  leg 
was  broken,  and  cried  out  lustily 
whenever  it  was  moved.    The  father 

arrived    in  about  an  hour,   and  found        Dislocation  down  wards  and  forwards  into  the 

him  still  lying  on  his  back  where  he  foramen  thyroideum. 
had  fallen,  with  his  right  leg  carried 

away  from  the  other,  and  turned  outwards.  He  lifted  him  up  to  place 
him  in  a  small  hand-wagon,  which  was  long  enough  for  his  body,  but 
only  one  foot  and  a  half  in  width.  Finding  that  his  right  leg  was  so 
much  abducted  as  to  prevent  his  being  laid  in  so  narrow  a  space,  he 
seized  upon  it,  and  with  some  force  pressed  the  knee  _  inwards  across 
the  opposite  leg,  when  suddenly  it  resumed  its  position  with  a  loud 
snap  like  a  "  cannon."  I  use  the  language  of  the  father.  On  the 
following  day  I  examined  the  limb  carefully,  and  found  its  motion 


670  DISLOCATIONS    OF    THE    THIGH. 

free.  He  was,  however,  vomiting  the  contents  of  his  stomach,  and 
passing  blood  from  the  bladder  quite  freely.  The  vomiting  soon 
ceased,  but  the  hemorrhage  from  the  bladder  continued  three  or  four 
days.  On  the  ninth  day  he  walked  out,  and  on  the  twelfth  he  was 
seen  climbing  upon  the  top  of  a  house.  I  saw  him  again  after  the 
lapse  of  a  year,  and  found  that  he  was  still  complaining  of  an  occa- 
sional soreness  in  the  region  of  the  hip-joint. 

If  we  attempt  to  reduce  by  manipulation,  it  will  be  proper  to  follow 
the  same  rule  which  we  have  stated  as  applicable  to  dislocations  back- 
Avards,  namely,  to  carry  the  limb  in  the  first  instance  only  in  those  di- 
rections in  which  it  is  found  to  move  easily.  Instead,  therefore,  of  hold- 
ing the  leg  in  a  position  of  adduction  while  the  thigh  is  flexed  upon  the 
abdomen,  it  will  be  necessary  to  carry  it  up  abducted ;  and  when  the 
further  progress  of  the  knee  toward  the  belly  is  arrested,  the  limb  must 
be  moved  inwards,  and  finally  brought  down  adducted.  When  the  knee 
is  about  opposite  the  pubes,  or  a  little  lower,  in  its  descent,  the  femur 
should  be  gently  rotated  inwards,  for  the  purpose  of  directing  the  head 
toward  the  acetabulum.  The  reduction  may  also  be  sometimes  facili- 
tated by  lifting  the  head  of  the  bone  with  the  aid  of  a  band  passed 
under  the  upper  portion  of  the  thigh  and  over  the  shoulder  of  an 
assistant ;  bj''  giving  to  the  shaft  of  the  femur  a  slight  rocking  motion 
when  it  is  about  to  enter  the  socket ;  and  also  by  pressing  with  the 
hand  against  the  head  of  the  bone,  or  by  lifting  at  the  knee  moderately. 

In  one  of  the  examples  recorded  by  Markoe  (Case  8),  the  reduction 
was  accomplished  in  the  second  attempt,  by  rotating  the  thigh  inwards 
just  as  the  thigh  had  descended  below  a  right  angle  with  the  body, 
in  the  manner  which  we  have  above  directed  ;  but  in  a  second  example 
(Case  9),  a  similar  manoeuvre  carried  the  head  across  into  the  ischiatic 
notch,  while  the  reduction  was  finally  accomplished  by  rotating  the 
thigh  outwards,  and  at  the  same  moment  adducting  the  limb  strongly 
in  a  direction  which  carried  the  knee  behind  the  other  one.  Markoe 
concludes  that  the  latter  mode  is  preferable,  because  it  will  throw  the 
head  of  the  bone  a  little  upwards  as  well  as  outwards ;  in  which  direc- 
tion it  will  find  a  more  gently  inclined  plane  toward  the  socket.  He 
admits,  however,  that  both  methods  may  accomplish  the  same  result. 
But  I  am  quite  certain  that  the  method  by  rotation  of  the  shaft  of  the 
femur  inwards  is  in  general  most  likely  to  succeed.  In  this  way  also, 
I  think,  both  W.  H.  Van  Buren,  of  New  York,^  and  R,  L.  Brodie,  of 
the  U.  S.  Army,  were  successful  f  it  is  the  method  preferred  by 
Bigelow,  who  also  recognizes  the  propriety  of  making  outward 
rotation  when  inward  rotation  fails.  "Flex  the  limb  towards  a  per- 
pendicular, and  abduct  it  a  little  to  disengage  the  head  of  the  bone; 
then  rotate  the  thigh  strongly  inward,  adducting,  and  carrying  the 
knee  to  the  floor."  It  is  especially  worthy  of  notice  that  Anderson, 
so  long  ago  as  1772,  in  the  case  already  quoted  when  we  were  con- 
sidering the  history  of  reduction  by  manipulation,  practised  success- 

'  W.  H.  Van  Buren,  New  York  ]\red.  Times,  Jan.  1856,  p.  127. 
2  R.  L.  Brodie,  Memphis  Med.  Recorder,  Sept.  1857,  p.  93;   from  Charleston 
Med.  Rev. 


INTO    THE    FORAMEN    THYROIDEUM, 


671 


fully  almost  precisely  the  same  method.  In  one  example  mentioned 
by  Markoe  (Case  7),  it  is  pretty  evident  that  the  head  of  the  femur 
was  thrown  into  the  ischiatic  notch,  by  having  flexed  the  thigh  too 
much,  so  that  "  the  knee  touched  the  thorax."     Indeed,  it  is  question- 


Fis.  294. 


Eeduction  of  thyroid  dislocation  by  manipulation.     (From  Bigelow.) 

able  whether  it  will  be  best  ever  to  bring  the  thigh  much,  if  at  all, 
above  a  right  angle  with  the  body,  since  any  further  flexion  can  only 
throw  the  head  below  the  acetabulum,  when  in  fact  it  is  already  too 
low. 

,  July  21,  1858,  Nathaniel  Smith,  a  painter  by  trade,  set.SS,  fell  from 
the  second-story  window  of  the  city  post-oflice,  Buffalo,  upon  a  stone 
pavement,  striking,  as  he  believes,  upon  the  inside  of  his  right  knee. 
I  saw  him  within  an  hour,  and  found  the  right  tibia  partially  dislocated 
outwards,  the  corresponding  patella  dislocated  completely  outwards, 
and  the  right  femur  in  the  foramen  thyroideum.  His  thigh  was  forci- 
bly abducted,  slightly  rotated  outwards,  and  lengthened,  by  measure- 
ment made  from  the  pelvis  to  the  ankle,  one  inch  and  a  half.  The 
distance  from  the  anterior  superior  spinous  process  to  the  fold  of  the 
groin  was  ten  inches,  but  upon  the  sound  side  it  was  only  eight  and  a 
half.  The  head  of  the  femur  could  be  distinctly  felt  in  front,  just 
under  the  pubes. 

Having  administered  chloroform,  I  first  reduced  the  tibia  and  the 
patella,  then  seizing  the  thigh  and  leg,  I  flexed  the  thigh  upon  the 
body,  carrying  the  limb  upwards  abducted  until  it  was  nearly  or  quite 
at  a  right  angle  with  the  body,  then  inclining  the  knee  slightly  in- 


672 


DISLOCATIONS    OF    THE    THIGH. 


wards,  I  brought  it  dowu  again,  and  when  the  thigh  had  nearly  reached 
the  bed,  it  fell  into  its  socket  with  a  dull  flapping  sensation.  In  every 
step  of  the  procedure  I  followed  the  inclination  of  the  limb.  The 
recovery  was  rapid  and  complete. 

Sir  Astley  Cooper  says  that  this  dislocation  is  in  general  reduced 
very  easily  by  the  aid  of  pulleys ;  at  least  if  the  accident  is  recent. 

Fia:.  295, 


Sir  Astley  Cooper's  mode  of  reducing  a  recent  luxation  into  the  foramen  thyroideum. 

He  advises  that  the  patient  shall  be  placed  upon  his  back,  with  his 
thighs  separated  as  far  as  possible.  The  pulleys  are  to  be  made  fast 
to  a  band  drawn  through  the  perineum  of  the  dislocated  limb,  in  a 
direction  upwards  and  outwards;  while  a  counter-band  is  to  be  passed 
around  the  pelvis  through  the  band  attached  to  the  pulleys,  and  secured 
to  a  staple,  or  delivered  to  assistants  placed  upon  the  sound  side  of  the 
body.  When  everything  is  arranged,  the  pulleys  should  be  acted  upon 
until  the  head  of  the  femur  is  felt  moving  from  the  foramen  ovale ;  at 
this  moment  the  surgeon  must  pass  his  hand  behind  the  sound  limb, 
and  seizing  upon  the  ankle  of  the  dislocated  limb,  adduct  it  forcibly, 
thus  converting  the  limb  into  a  lever  of  the  first  order. 

If  the  dislocation  has  existed  some  time,  he  recommends  that  this 
procedure  shall  be  varied  by  placing  the  patient  upon  his  sound  side 
instead  of  his  back,  and  attaching  the  pulleys  perpendicularly  over 
the  body.  Sir  Astley  especially  cautions  us  not  to  flex  the  thigh  during 
these  manoeuvres,  lest  we  force  the  head  of  the  bone  backwards  into 
the  ischiatic  notch,  from  whence  he  affirms  that  it  cannot  afterwards 
be  returned  to  its  socket ;  but  the  experience  of  surgeons  has  since 
shown  that  this  latter  statement  is  incorrect,  and  that  it  may,  in  some 
cases,  be  afterwards  reduced,  although  it  has  fallen  into  the  ischiatic 


IIS^TO    THE    FORAMEX    TPIYEOIDEUM. 


673 


notcli.  Mr.  Listen  says  that  this  accident  happened  to  himself  while 
attempting  to  reduce  a  dislocation  of  only  a  few  hours'  standing,  in  a 
young  and  powerful  mau,  but  he  had  no  difficulty  in  returning  it  to 
its  first  position.^ 

Brainard,  of  Chicago,  reduced  a  dislocation  of  that  form  of  which 
we  are  now  speaking,  after  both  the  compound  pulleys  and  Jarvis's 
adjuster  had  failed,  by  placing  betAveen  the  thighs  a  piece  of  wood 
wrapped  about  with  several  layers  of  a  wadded  quilt,  and  making 
use  of  this  as  a  fulcrum  upon  which  the  thigh  operated  as  a  lever. 
The  legs  were  simply  pressed  together,  care  being  taken  to  keep  the 
knees  straight.^ 

The  majority  of  surgeons  of  the  present  day  place  the  limb  in  the 
flexed  position  before  attempting  to  make  traction.  This  may  be 
done   with   the   patient    lying 

upon  his  back,  and  by  the  hands  Fi.?.  296. 

alone,  or  with  pulleys,  or  the 
patient  may  be  placed  in  a  sit- 
ting posture,  and  the  extension 
made  at  right  angles  with  the 
body.  In  all  of  these  attempts 
to  reduce  by  traction,  measures 
must  be  taken  to  secure  immo- 
bility to  the  pelvis. 

May  23,  1868,  a  man.  40 
years  of  age,  was  admitted  to 
Bellevue,  having  a  dislocation 
of  the  left  femur  into  the  fora- 
men thyroideum,  which  had 
been  caused  six  hours  before 
by  the  fall  of  a  heavy  weight 
upon  his  back  while  stooping. 
The  limb  was  slightly  abduc- 
ted, and  moderately  flexed 
upon  the  pelvis,  while  he  was 
lying  upon  the  bed  the  position 
being  that  represented  in  Fig. 
293.  There  was  a  very  marked  depression  in  the  situation  of  the 
trochanter  major,  and  a  fulness  upon  the  inside  of  the  limb,  caused 
by  the  tension  of  the  long  adductors. 

The  patient  being  under  the  influence  of  ether,  the  HouseSurgeon, 
Dr.  E.  D.  Hudson,  first  attempted,  under  my  instruction,  to  reduce  the 
dislocation  by  manipulation,  flexion,  and  rotation,  with  adduction; 
but  failing  in  this,  a  folded  sheet  was  placed  in  the  perineum  corre- 
sponding to  the  dislocated  limb,  and  committed  to  assistants,  who  were 
directed  to  pull  upwards  and  outwards,  the  patient  lying  upon  his 
right  side,  with  his  left  thigh  flexed  to  a  right  angle  with  his  body. 
Dr.  Hudson  then  passed  a  band  under  the  upper  part  of  the  thigh  and 

'  Practical  Sura:.,  Amcr.  ed.,  p,  93. 

2  Braiuard,  Nortliwestern  Med.  and  Surg.  Jouru.,  1853. 


Effect  of  flexion  upon  the  ilio-femoral  ligament  in  tlie 
tliyroid  dislocation.     (From  Bigelow.) 


674  DISLOCATIONS    OF    THE    THIGH. 

over  bis  shoulders,  lifting  and  pressing  the  knee  forcibly  inwards  at 
the  same  time.     In  a  few  seconds  the  reduction  was  accomplished. 

After  the  reduction  is  accomplished,  the  patient  should  be  laid  upon 
his  back  in  bed,  but  instead  of  rotating  the  limb  outwards,  as  we  have 
advised  after  a  dislocation  upon  the  dorsum  ilii  or  into  the  ischiatic 
notch,  it  should  be  gently  rotated  inwards,  and  the  knees  thus  bound 
together. 

§  4.  Dislocations  Upwards  and  Forwards  upon  the  Pubes. 

Syn. — "Upwards  and  forwards  on  the  horizontal  branch  of  the  share-bone;" 
Chelius.  "Forwards  upon  the  pubes  ;"  Pirrie.  "  On  the  body  of  the  pubes,  below 
the  spine  and  transverse  part  of  the  bone  ;"  Skey.  " Sur-pubic  ;"  Gerdy.  "Ilio- 
pubic;" Malgaigne. 

Causes. — This  accident  is  generally  occasioned  by  a  fall  upon  the 
foot  when  the  leg  is  thrown  backwards  behind  the  centre  of  gravity; 
as  in  a  fatl  from  the  back  end  of  a  wagon,  the  foot  being  instinctively 
thrown  backwards  in  order  to  save  the  head;  or  it  may  happen  to  a 
person  who,  while  walking,  suddenly  puts  one  foot  into  a  hole,  in 
consequence  of  which  the  pelvis  advances,  but  the  leg  and  upper  part 
of  the  body  incline  forcibly  backwards.  Occasionally  it  has  resulted 
from  a  fall  upon  the  back  of  the  pelvis,  or  from  a  severe  blow  received 
upon  the  same  part.  A  patient  was  admitted  under  the  care  of  Dr. 
lire,  into  St.  Mary's  hospital,  London,  with  a  dislocation  upon  the 

Fig.  297. 


I 


Specimen  of  dislocation  upon  the  putes,  in  St.  Thomas's  Hospital.     (From  Sir  A.  Cooper.) 

pubes,  occasioned  by  swimming.  His  account  of  it  was,  that  when 
in  the  act  of  "  striking  out"  he  felt  a  catch  in  the  right  groin  which 
he  thought  was  cramp,  and  that  he  was  able  to  walk  after  the  accident, 
but  with  a  good  deal  of  difficulty.  The  examination  proved  that  he 
had  a  dislocation  upon  the  pubes,  which  Dr.  Ure  easily  reduced.^ 

I  Medical  News  and  Library,  vol.  xvi.  p.  1;  from  Lond.  Lancet,  Nov.  7,  1807. 


UPWAEDS  AND  FORWARDS  UPON  THE  PUBES. 


675 


Pailiological  Anatomy. — Sir  Astley  Cooper  dissected  the  hip  of  a 
person  whose  thigh  had  been  dislocated  upon  the  pubes  for  some  time, 
the  true  nature  of  the  accident  not  having  been  at  first  recognized. 
The  acetabulum  was  partly  filled  by  bone,  and  partly  occupied  by  the 
trochanter  major,  both  of  which  were  much  altered  in  their  form.  The 
capsular  ligament  was  extensively  torn,  and  the  ligamentum  teres 
broken  off  completely.  The  head  and  neck  of  the  femur  had  torn  up 
Poupart's  ligament,  so  as  to  penetrate  between  it  and  the  pubes,  and 
lay  underneath  the  iliacus  internus  and  psoas  muscles;  the  anterior 
crural  nerve  was  lying  upon  these  muscles,  over  the  neck  of  the  femur. 
The  head  and  neck  were  flattened  and  otherwise  much  changed  in 
form.  Upon  the  pubes  a  socket  was  formed  for  the  neck  of  the  thigh- 
bone, the  head  being  above  the  level  of  the  pubes.  The  femoral  artery 
and  vein  were  to  the  inner  side.  This  specimen  is  still  preserved  in 
St.  Thomas's  flospital. 

The  head  of  the  femur  may  be  found  lying  far  forward'  upon  the 
pubes,  as  in  Physick's  case  mentioned  below;  or  it  may  lie  farther 
back,  along  the  ilio-pubic  mar- 
gin, and  rest  below  and  in  front  Fig-  298. 
of  the  anterior  superior  spinous 
process  of  the  ilium.    When  the 
head  rests  directly  below  this 
process,  the  dislocation  is  con- 
sidered anomalous  or  irregular, 
and  this  form  will  be  considered 
hereafter  as  the   "  sub-spinous" 
dislocation. 

In  the  accompanying  drawing 
the  relation  of  the  ilio-femoral 
ligament  to  the  head  and  neck 
of  the  femur  is  shown,  when  the 
head  ascends  moderately  upon 
the  pubes.  The  extreme  dis- 
placement shown  in  the  pre- 
ceding illustration  from  Sir 
Astley  Cooper  is  only  possible 
where  that  portion  of  the  cap- 
sule beneath  the  obturator  in- 
ternus is  torn,  and  perhaps  the 
obturator  itself. 
Bigelow,  the  ilio-femoral 
ment  and  the  psoas  magnus  and 
iliacus  internus  are  then  the  only 
remaining  causes  of  eversion. 

Sympto'ins. — The  thigh  is 
shortened,  abducted,  flexed 
slightly,  rarely  extended,  and 
rotated  outwards.  The  trochanter  major  is  lost,  or  nearly  so,  while 
the  head  of  the  bone  may  be  generally  felt  like  a  round  ball,  lying 
upon  or  in  front  of  the  body  of  the  pubes  to  the  outside  of  the  femoral 


According  to 
liga- 


Dislocation  upon  the  pubes  'below  the  anterior 
ferior  spine  of  the  ilium.     (From  Bigelow.) 


676 


DISLOCATIONS    OF    THE    THIGH. 


artery  and  vein.  Larrey  saw  a  patient  in  Avhoni  the  femur  was  placed 
nearly  at  a  right  angle  with  the  body ;  and  Physick  once  met  with  a 
dislocation  upon  the  pubes  "  directly  before  the  acetabulum,"  in  which 
the  limb  was  not  at  all  shortened,  but,  on  the  contrary,  a  very  little 
lengthened.^  Other  surgeons  have  occasionally  seen  similar  examples. 
The  diflferential  diagnosis  between  a  fracture  of  the  neck  of  the 
femur  and  this  dislocation  may  be  thus  briefly  stated.     In  the  fracture 

there  is  crepitus,  mobility,,  slight 
rig.  299.  eversion  easily  overcome,  mode- 

rate or  no  shortening,  no  abduc- 
tion, the  trochanter  major  rotates 
on  a  short  radius,  the  head  of  the 
bone  cannot  be  felt.  In  this  dis- 
location there  is  no  crepitus,  the 
limb  is  immobile,  the  eversion  is 
extreme  and  not  easily  overcome, 
there  is  generally  more  shortening, 
the  thigh  is  abducted,  the  tro- 
chanter major  rotates  upon  a 
longer  radius,  and  the  head  of  the 
bone  can  generally  be  distinctly 
felt  in  its  unnatural  position. 

Prognosis. — Sir  Astley  Cooper 
remarks  that  although  this  acci- 
dent is  easy  of  detection,  he  has 
known  three  instances  in  which  it 
was  overlooked,  and  he  cannot 
but  regard  such  errors  as  evidence 
of  great  carelessness  on  the  part 
of  the  surgeon  who  is  employed. 
The  reduction  has  generally 
been  accomplished,  in  recent  cases, 
with  no  great  difl&culty ;  and  when 
not  reduced,  the  patients  have  oc- 
casionally recovered  with  very 
useful  limbs. 

Treatment. — From  the  several 
reported  examples  of  dislocation 
upon  the  pubes  reduced  by  ma- 
nipulation, it  would  be  difficult  to 
draw  any  practical  conclusions, 
since  the  methods  have  differed 
so  widely  from  each  other.  I 
shall  mention  only  three,  which 
may  be  found  in  our  own  journals. 
One  of  these  has  already  been  mentioned  in  connection  with  the 
history  of  this  process,  as  a  case  of  compound  dislocation,  reduced  by 
Dr.  Ingalls,  of  Chelsea,  Mass.,  and  the  two  remaining  examples  were 
both  reported  by  E.  J.  Fountain,  of  Davenport,  Iowa.     Dr.  Ingalls 


Dislocation  upwards  and  forwards  upon  the  pubes. 


'  Dorsey's  Surgery,  vol.  i.  p.  238,  1813. 


UPWARDS  AXD  FORWAEDS  UPOX  THE  PUBES.    677 

succeeded  by  carrying  the  limb  into  its  greatest  state  of  abduction,  and 
rotating  the  thigh  inwards;  the  replacement  of  the  bone  being  aided 
also  by  pressing  upon  its  head  with  his  fingers  thrust  into  the  wound  ; 
while  Dr.  Fountain  succeeded  equally  iu  both  of  his  cases,  by  an  al- 
most opposite  mode  of  procedure,  namely,  by  adducting  the  limb  for- 
cibly, rotating  the  thigh  outwards,  and  then  flexing  the  thigh  upon  the 
body.  The  first  of  Dr.  Fountain's  cases  occurred  in  June,  1854.  The 
patient,  an  adult  male,  had  fallen  from  the  second  story  of  a  house  to 
the  ground,  fracturing  his  lower  jaw,  and  dislocating  his  left  hip.  The 
limb  was  a  trifle  shortened,  and  the  foot  strongly  everted.  The  promi- 
nence of  the  trochanter  was  lessened,  and  the  head  of  the  bone  could 
be  felt  upon  the  pubes.  Assisted  by  Dr.  Arnold,  he  reduced  the  limb 
in  the  following  manner  :  The  patient  was  laid  on  the  floor,  and  placed 
completely  under  the  influence  of  chloroform.  The  dislocated  limb 
was  then  "seized  by  the  foot  and  knee  and  rotated  outwards,  the  leg 
flexed  and  carried  over  the  opposite  knee  and  thigh,  the  heel  kept 
well  up,  and  the  knee  pressed  down.  This  motion  was  continued  by 
carrying  the  tliigh  over  the  sound  one  as  high  as  the  upper  part  of 
the  middle  third,  the  foot  being  kept  firmly  elevated.  Then  the  limb 
was  carried  directly  upwards  by  elevating  the  knee,  while  the  foot 
was  held  firm  and  steady,  at  the  same  time  making  gentle  oscillations 
by  the  knee,  when  the  head  of  the  bone  suddenly  dropped  into  its 
socket.'"  The  time  occupied  was  not  more  than  thirty  seconds,  and 
the  force  employed  was  very  slight. 

The  second  case  occurred  on  the  31st  of  Oct.  1855,  in  the  person 
of  John  McCarthy,  an  Irish  laborer ;  the  dislocation  having  been 
occasioned  by  falling  with  a  horse,  while  riding.  The  reduction  was 
effected  in  about  twenty  seconds  by  the  same  process,  and  without  the 
aid  of  chloroform. 

It  is  probable  that  no  one  method  will  succeed  equally  well  in  all 
cases ;  but  if  the  head  of  the  bone,  as  in  the  case  dissected  by  Sir 
Astley  Cooper,  has  not  only  actually  surmounted  the  pubes,  but 
pushed  itself  fairly  into  the  pelvis,  then  the  limb  ought  to  be  abducted 
in  the  manner  practised  by  Ingalls,  and  forcibly  rotated  outwards,  in 
order  that  the  head  may  be  thus  lifted  over  the  pubes ;  and  subse- 
quently it  should  be  flexed  upon  the  body,  adducted  and  brought 
down.  But  in  this  manoeuvre  we  ought  to  be  careful  not  to  continue 
the  rotation  outwards  after  the  head  of  the  femur  has  risen  above  the 
pubes,  lest  the  head  and  neck  should  grasp,  as  it  were,  the  psoas 
raagnus  and  iliacus  internus  muscles,  underneath  which  they  have 
been  thrust.  On  the  contrary,  it  will  be  necessary  at  this  point  to 
rotate  the  thigh  again  gently  inwards,  which,  by  compelling  the  head 
to  hug  the  front  of  the  pubes,  will  enable  it,  while  the  flexion  is  being 
made,  to  slide  downwards  under  these  muscles  toward  the  socket,  Ifj 
however,  the  head  of  the  bone  has  never  risen  upon  the  summit  of  the 
pubes,  and  is  not  actually  engaged  under  the  muscles  which  pass  over 
it  at  this  point,  then  the  rotation  outwards  will  not  be  necessary  in 
any  part  of  the  procedure. 

'  Fountain,  New  York  Journ.  Med.,  Jan.  1856,  p.  69  et  seq. 


678 


DISLOCATIONS    OF    THE    THIGH, 


Baron  Larrey  has  reported  a  case  of  dislocation  "  before  tbe  hori^ 
zontal  portion  of  the  pubes,"  which  he  reduced  "  by  suddenly  raising 
with  his  shoulder  the  lower  extremity  of  the  femur,  while  with  both 
hands  he  depressed  the  head  of  the  bone."^  This  is  the  same  case  of 
which  we  have  already  spoken  as  being  attended  with  the  unusual 
phenomenon  of  the  thigh  placed  at  a  right  angle  with  the  body. 

If  reduction  is  attempted  by  extension,  the  patient  ought  to  be  laid 
on  his  back  upon  a  table,  with  the  dislocated  limb  falling  off'  slightly 
from  its  side.  The  extending  band,  made  fast  above  the  knee,  should 
then  be  secured  to  a  staple  in  the  line  of  the  axis  of  the  dislocated 
thigh,  and  of  course  below  the  table;  while  the  counter-extending 
band,  crossing  under  the  perineum,  should  be  made  fast  in  the  same 
line,  above  the  level  of  the  table,  and  beyond  the  head  of  the  patient. 

When  extension  is  commenced,  and  the  head  of  the  femur  has 
begun  to  move,  the  reduction  may  sometimes  be  facilitated  by  lifting 

Fi?.  300. 


Reduction  of  dislocation  upon  the  pubes,  by  extension. 

the  upper  part  of  the  thigh  with  a  jack-towel  or  a  band  passed  under 
the  thigh  and  over  the  neck  of  the  surgeon,  as  we  have  recommended 
in  both  of  the  backward  dislocations.  It  may  be  found  advantageous 
also  to  flex  and  rotate  the  limb  after  extension  has  brought  the  head 
near  the  socket. 

§  5.  Anomalous  Dislocations,  or  Dislocations  which  do  not  properly 
belong  to  either  of  the  four  principal  divisions  before  described.^ 


1.  Dislocations  directly  Upwards. 
A^^ft.— "Sus-Cotyloidienues;"  Malgaigne.     "  Sixth  dislocation ;"  Miitter. 

Malgaigne  affirms  that  the  head,  in  this  dislocation,  is  situated 
external  to  the  anterior  inferior  spinous  process,  and  about  one  inch 

1  Larrey,  Loud.  Med-Chir.  Rev.,  Dec.  1820,  p.  500  ;  vol.  i.  first  ser.,  from  Bullet, 
de  la  Fac.  de.  Med.,  No.  1. 

5  Malgaigne,  Traite  des  Frac.  et  des  Lux.,  torn.  ii.  p.  869  et  seq.  Samuel  Cooper, 
First  Lines,  vol.  ii.  p.  391.  Pirrie's  Surg.,  Amer.  ed.,  1853,  p.  275.  Skey's  Surg., 
Amer.  ed.,  1851,  p.  110  et  seq.     Gibson's  Surg.,  sixth  Amer.  ed.,  vol.  i.  p.  386. 


ANOMALOUS    DISLO  C  ATIOXS.  679 

below  the  anterior  superior  spinous  process  ("sub-spinous").  But  this 
position  is  not  uniform.  It  may  be  found  in  front  of  the  inferior  pro- 
cess, or  above  ("supra-spinous")  as  well  as  behind,  or  external  to  it. 

The  symptoms  which  characterize  this  accident  are  shortening  of 
the  limb,  slight  abduction  and  extension,  with  extreme  eversion  or 
rotation  outwards.  The  eversion  of  the  toes,  together  with  the  slight 
amount  of  shortening  which  has  in  general  been  observed,  has  led 
several  times  to  the  supposition  that  it  was  a  fracture  of  the  neck  of 
the  femur ;  but  the  rigidity,  and  the  position  of  the  trochanter  and 
head  will  usually  render  the  diagnosis  clear. 

The  following  is  probably  an  example  of  the  sub-spinous  disloca- 
tion : — 

Bennett  Morris,  £et.  51,  was  thrown  backward,  in  wrestling,  in  1851. 
He  felt  a  snap  in  the  hip-joint,  and  found  his  thigh  placed  in  a  position 
of  moderate  abduction,  so  that  he  could  not  get  his  knees  together. 
He  was  able  to  walk,  but  not  without  limping.  This  condition  con- 
tinued three  years,  during  which  time  he  was  constantly  lame,  and 
sufl'ered  much  pain  when  walking. 

At  the  end  of  this  period,  when  in  the  act  of  jumping  from  his 
wagon,  his  horses  having  become  frightened,  he  felt  a  snap,  and  at  once 
the  complete  functions  of  the  joint  were  restored.  He  could  walk 
without  pain  or  halt,  and  he  could  bring  his  knees  together.  Three 
months  later,  while  ascending  a  flight  of  steps,  carrying  a  heavy  weight, 
his  foot  slipped,  and  the  luxation  was  reproduced,  and  in  this  condi- 
tion it  remained  up  to  the  period  at  which  he  consulted  me,  Oct.  1869. 
I  found  the  thigh  apparently  elongated,  but  upon  measurement  it  was 
found  shortened  half  an  inch.  It  was  moderately  abducted  arid  ro- 
tated outwards.     All  the  motions  of  the  joint  were  restricted. 

Although  I  felt  very  confident  that  the  reduction  could  be  again 
accomplished,  the  patient  left  without  permitting  me  to  make  the 
attempt. 

Other  surgeons  have  met  with  examples  of  the  upward  dislocation 
(sub-spinous)  in  which  the  patients  have  been  able  to  walk  quite  well 
immediately  after  the  accident.  Bigelow  supposes  that  in  these  cases 
the  upper  portion  of  the  capsule  has  been  completely  torn  from  the 
margin  of  the  acetabulum,  and  that  the  head  has  been  permitted  to 
ascend  until  it  was  arrested  by  the  under  surface  of  the  ilio-femoral 
ligament  at  the  point  where  it  rises  from  the  anterior  inferior  spinous 
process  of  the  ilium. 

Cummins  reports  a  case  which  occurred  in  the  practice  of  Gibson, 
of  New  Lanark,  where  the  head  of  the  bone  was  believed  to  be  situated 
just  below  the  anterior  superior  spinous  process,  and  inwards  towards 

Guy's  Hospital  Reports,  vol.  i.,  1836,  pp.  79  and  97 ;  vol.  iii.,  1838,  p.  163.  London 
Lancet,  Lond.  ed.,  vol.  i.,  1848,  p.  184;  vol.  ii.,  1840,  p.  281 ;  vol.  i.,  1845,  p.  413, 
vol.  ii.  p.  159.  London  Med.  Gaz.,  vol.  xix.  pp.  057  and  659;  vol.  x.  p.  19;  vol. 
xxxiii.  p.  404.  Med.-Cliir.  Trans.,  vol.  xx.  p.  113.  Lente's  paper  on  •'Anomalous 
Dislocations  of  the  Hip-Joint,"  in  New  York  Journ.  Med.  for  Nov.  1850,  p.  314  ct 
seq.  Philadelphia  Med.  Examiner,  No.  51.  Amer.  Journ.  Med.  Sci.,  vol.  xvi.  p. 
14.  New  York  Med.  and  Phys.  Journ.,  1826,  vol.  v.  p.  597.  New  York  Journ. 
Med.,  Jan.  1860,  Dr.  Shrady's  case.  Dislocation  of  the  Hip,  by  Jacob  J.  Bigelow, 
M.D.,  1809,  p.  105. 


680  DISLOCATIONS    OF    THE    THIGH. 

the  pubes  ("  supra-spinoiis").  The  limb  was  shortened  fully  three  inches ; 
the  toes  everted ;  adduction  and  abduction  were  exceedingly  painful 
and  difficult,  but  flexion  was  more  easily  performed.  The  head  of  the 
bone  could  be  felt  in  its  new  position,  especially  when  the  thigh  was 
moved.  At  first  it  was  supposed  to  be  a  fracture,  but  this  error  having 
been  corrected,  the  surgeons  proceeded  to  attempt  reduction  on  the 
eleventh  day.  Extension  was  made  by  pulleys,  and  when  the  head  of 
the  bone  had  descended  to  the  margin  of  the  cavity,  Mr.  Gibson  lifted 
the  upper  end  of  the  femur  by  means  of  a  towel,  at  the  same  moment 
pressing  the  knee  toward  the  opposite  thigh,  and  forcibly  rotating  the 
limb  inwards;  by  which  means  the  reduction  was  accomplished.^ 

Lente  has  seen  the  head  of  the  femur  in  the  same  position  as  in  the 
case  reported  by  Cummins,  not  as  a  primitive  dislocation,  but  conse- 
quent upon  an  attempt  to  reduce  a  dislocation  into  the  ischiatic  notch. 
The  shortening  was  about  two  inches ;  the  limb  very  much  rotated 
outwards ;  the  rotundity  of  the  affected  hip  greater  than  that  of  the 
other,  and  the  trochanter  major  one  inch  farther  removed  from  the 
anterior  superior  spinous  process.  The  head  of  the  bone  could  be 
felt  distinctly  in  its  new  position. 

The  reduction  was  effected  finally  with  pulleys,  by  the  aid  of  chlo- 
roform, and  by  rotation  of  the  limb  in  various  directions.^ 

Morgan  also  reports  a  case  in  which  the  head  of  the  femur  was 
above  the  acetabulum,  and  a  little  to  the  outside  of  the  ilio-pectineal 
eminence^  ("sub-spinous"). 

In  a  majority  of  cases  these  dislocations  have  been  reduced  by 
manipulation  alone,  or  by  manipulation  aided  by  pressure.     The  limb 

Fiff.  301. 


Anterior  oblique  dislocation.     (From  Bigelow.) 

should  be  seized  in  the  usual  manner,  at  the  knee  and  ankle,  car- 
ried up  toward  the  face,  abducted,  then  rotated  inwards,  gently  ad- 
ducted,  and  finally  brought  down  again  to  the  bed.  At  the  moment 
when  the  rotation  and  adduction  commence,  the  head  of  the  bone 
should  be  pressed  toward  the  socket  by  the  hands,  and,  if  necessary, 

•  Cummins,  Guy's  Hospital  Reports,  vol.  iii.  p.  163,  1838. 

2  Lente,  New  York  Journ.  of  Med.,  Nov.  1850,  p.  314. 

3  Pirrie's  Surgery,  p.  276.     See  also  Phil.  Med.  Exam.,  No.  51,  Mutter's  paper. 


ANOMALOUS    DISLOCATIONS. 


681 


lifted  a  little  over  the  margin  of  the  acetabulum,  by  moderate  exten- 
sion at  a  right  angle  with  the  body. 


Fiff.  302. 


Mechanism  of  anterior  oblique  dislocation.     (From  Bigelow.) 

Bigelow,  who  regards  as  irregular  only  those  which  are  accom- 
panied with  a  complete  rupture  of  the  ilio-femoral  ligament,  but  whose 
classification  in  that  regard  I 

am  not  fully  prepared  to  adopt,  Fig.  303. 

has  nevertheless  given  us  the 
most  intelligible  and  most  pro- 
bable explanation  of  the  me- 
chanism of  these  irregular  up- 
wards dislocations,  and  of  seve- 
ral other  forms  of  irregular  dis- 
locations.  According  to  this 
writer,  the  "anterior  oblique 
dislocation,"  in  which  the  limb 
is  found  greatly  adducted,  and 
at  the  same  time  strongly  evert- 
ed, is  a  regular  dorsal  disloca- 
tion, the  head  being  advanced 
upon  the  dorsum  to  a  point  near 
the  anterior  margin  of  the  ilium. 
If  now  the  limb  be  brought 
down,  the  neck  of  the  femur 
will  be  made  to  bear  against 
the  outer  fibres  of  the  ilio- 
femoral ligament,  and  as  these 
gradually  give  way  the  head 
will  become  more  and  more  hooked  over  the  remaining  fibres  of  the 
ligament,  and  above  the  inferior  spinous  process  ("  supra-spinous") ; 
or,  continued  efforts  being  made  to  straighten  the  limb,  the  ligament 
44 


Supra-spinous  dislocation.     (Bigelow.) 


682  DISLOCATIONS    OF    THE    THIGH. 

will  give  way  entirely,  and  the  femur  will  assume  the  position  indi- 
cated by  the  dotted  lines. 

Bigelow  recommends  a  plan  of  treatment  essentially  the  same  as 
that  hitherto  recommended  by  myself.  "  The  anterior  oblique  disloca- 
tion may  be  reduced  by  inward  circumduction  of  the  extended  limb 
across  the  symphysis,  with  a  little  eversion,  if  necessary,  to  disengage 
the  head  of  the  bone.  Inward  rotation  then  converts  this  into  the 
common  luxation  upon  the  dorsum."  In  the  siipra-sjiijious  disloca- 
tion, he  recommends  also  inward  circumduction,  with  as  much  ever- 
sion as  may  be  necessary  to  disengage  the  head  from  the  pelvis,  by 
which  the  dislocation  is  at  once  converted  into  dorsal. 

2.  Dislocations  Doivmvards  and  Backicards  itjjon  the  Posterior  Part  of  the 
Body  of  the  Ischium,  between  its  Tuberosity  and  its  Spine. 

James  C ,  set.  35,  was  admitted  to  the  Pennsylvania  Hospital  on 

the  23d  of  January,  1835,  under  the  care  of  Dr.  Hewson.  The  patient, 
a  muscular  man,  had  been  crushed  under  a  falling  roof,  and,  as  he 
thought,  with  his  right  thigh  separated  from  his  body.  When  received 
into  the  hospital,  one  hour  after  the  accident,  the  right  thigh  was  flexed 
upon  the  pelvis,  and  rested  upon  the  left ;  the  right  leg  was  also  flexed 
upon  the  thigh ;  the  knee  was  below  its  fellow,  the  toes  turned  in- 
wards, and  the  whole  limb  shortened  at  least  one  inch.  The  head  of 
the  bone  could  be  felt  distinctly  resting  upon  that  portion  of  the 
ischium  which  lies  between  the  acetabulum,  the  tuberosity  of  the 
ischium,  and  the  spine. 

On  the  following  day,  the  muscles  of  the  patient  having  been  sufii- 
ciently  relaxed  by  suitable  means,  the  pulleys  were  applied  ;  but,  after 
a  second  attempt,  some  of  the  bands  having  given  way  suddenly,  the 
pulleys  were  removed,  when  it  was  found  that  the  reduction  had  been 
accomplished,  although  neither  the  patient  nor  his  attendants  had 
noticed  the  return  of  the  bone  to  its  socket.  For  several  days  there 
was  entire  loss  of  sensibility  and  motion  in  the  leg,  owing  probably  to 
the  pressure  which  had  been  made  upon  the  sciatic  nerve;  but  these 
symptoms  gradually  disappeared,  and  at  the  time  when  the  case  was 
reported,  about  two  months  after  the  accident,  he  was  walking  with 
crutches. 

Dr.  Kirkbride,  who  has  reported  this  unusual  case  of  dislocation, 
doubts  whether  the  extension  was  necessary  to  the  reduction,  as  the 
head  of  the  bone  was  brought  very  near  the  margin  of  the  acetabulum 
by  lifting  the  thigh  with  a  towel,  and  it  probably  afterwards  entered 
the  socket  so  soon  as  the  extension  was  relaxed.' 

Malgaigne  has  referred  to  several  similar  examples. 

3.  Dislocations  Doivnicards  and  Backwards  into  the  lesser  or  lower  Ischi- 

atic  Notch. 
Syn. — "Beliind  tuber  iscliii ;"  Gibson,  S.  Cooper.     "  Fifth  dislocation  ;"  Gibson. 

September  7,  1821,  Charles  Lowell,  of  Lubec,  Mass.,  was  riding  a 
spirited  horse,  when  the  animal,  being  restive,  suddenly  reared  and  fell 

'  Kirkbride,  Amer.  Journ.  of  Med.  Sci.,  toI.  xvi.  p.  13. 


AXOMALOUS    DISLOCATIOXS.  683 

back  on  his  rider,  in  such  a  mariner  as  that  the  weight  of  the  horse 
was  received  on  the  inside  of  the  left  thigh  ;  Mr.  Lowell  having  fallen 
on  his  back,  a  little  inclined  to  the  left  side.  The  surgeon,  who  was 
immediately  called,  recognized  it  as  a  dislocation,  and  thought  he  had 
succeeded  in  reducing  it;  but  a  day  or  two  later  it  was  seen  by  a 
second  surgeon,  who  declared  that  it  was  still  out  of  place,  and  re- 
peated the  attempt  at  reduction,  but  without  success,  as  the  result 
proved. 

In  December  of  the  same  year  Mr.  Lowell  called  upon  John  C. 
Warren,  of  Boston,  who  was  now  able  to  determine,  easily,  as  he 
affirms,  the  precise  character  of  the  accident.  The  limb  was  elongated, 
contracted,  and  the  head  could  be  felt  in  its  unnatural  position.  By 
advice  of  Dr.  Warren,  he  was  taken  to  the  Massachusetts  General 
Hospital,  and  a  persevering  attempt  was  there  made  to  reduce  the 
bone,  but  with  no  better  success  than  had  attended  the  efforts  pre- 
viously made.^ 

Mr.  Keate  has  reported  a  case  produced  in  a  very  similar  way  by 
a  horse  having  fallen  backwards  with  the  rider  into  a  deep  and  narrow 
ditch ;  but  the  position  of  the  limb  was  somewhat  extraordinary,  con- 
sidering that  it  was  a  dislocation  backwards,  the  whole  limb  being 
very  much  abducted  and  the  toes  being  turned  outwards,  as  if  the  head 
of  the  bone  was  in  front  of  the  tuber  ischii,  rather  than  behind  it. 
The  thigh  and  leg  were  much  flexed,  and  the  whole  limb  was  short- 
ened from  three  to  three  and  a  half  inches.  The  head  of  the  femur 
could  be  distinctly  felt  "  inferior  to  the  ischiatic  notch,  and  on  a  level 
with  the  tuberosity  of  the  ischium."  In  the  first  attempt  at  reduction 
the  head  of  the  bone  was  thrown  into  the  foramen  ovale,  from  which 
it  was,  however,  after  one  or  two  more  attempts  by  extension,  and  by 
lifting  with  a  jack-towel,  restored  to  the  socket.  Mr.  Keate  believes 
that  the  dislocation  was  originally  into  the  foramen  ovale,  but  that  in 
the  struggles  made  by  the  patient  to  extricate  himself,  it  was  thrown 
backwards  into  the  position  in  which  he  found  it.^ 

Mr.  Wormald  has  reported  a  primitive  accident  of  the  same  kind, 
occasioned  by  jumping  from  a  third-story  window.  The  patient  died 
soon  after,  and  at  the  autopsy  the  head  of  the  femur  was  found  under 
the  outer  edge  of  the  gluteus  maximus,  projecting  through  the  torn 
capsule  opposite  the  upper  part  of  the  tuber  ischii.  The  shaft  of  the 
femur  lay  across  the  pubes,  and  the  limb  was  considerably  shortened 
and  turned  inwards.^ 

4.  Dislocations  Directly  Downwards. 

8yn. — "  Sous-cotyloidieunes ;"  Malgaigne. 

The  following  is  one  of  several  similar  examples  now  upon  record : — 

A  man,  aet.  50,  was  admitted  into  the  London  Hospital  under  the 

care  of  Mr.  Luke.     A  dislocation  of  the  left  femur  was  easily  diagnos- 

'  New  York  Med.  and  Phys.  Journ.,  vol.  v.  p.  597,  1826.  Letter  to  the  Hon. 
Isaac  Parker,  etc.,  by  John  C.  Warren  :  183G.  North  Amer.  Med.  Journ.,  vol.  iii. 
p.  169. 

2  Amer.  Journ.  Med.  Sci.,  vol  xvi.  p.  226,  1835;  from  Lond.  Med.  Gaz.,  vol.  .\. 
p.  19. 

3  Wormald,  London  Med.  Gaz.,  1836. 


684 


DISLOCATIONS    OF    THE    THIGH. 


ticated,  but  the  symptoms  were  peculiar,  inasmuch  as  the  limb  was 
lengthened  one  inch,  without  either  inversion  or  eversion ;  yet  the 
head  of  the  bone  could  be  easily  felt,  and  was  thought  to  be  in  the 
ischiatic  notch.  By  manipular  movements  reduction  was  easily  effected 
about  an  hour  after  the  accident.  The  man  subsequently  died  from 
the  effects  of  broken  ribs.  At  the  autopsy,  Mr.  Forbes,  the  house- 
surgeon,  before  dissecting  the  parts,  again  dislocated  the  bone.  This 
was  done  with  ease,  and  it  was  clear  that  the  original  form  of  disloca- 
tion had  been  reproduced,  as  the  bone  could  not  be  made  to  assume 
any  other  position.  The  head  of  the  bone  proved  to  be  displaced 
neither  into  the  ischiatic  notch  nor  the  thyroid  hole,  but  midway  be- 
tween the  two,  immediately  beneath  the  lower  border  of  the  acetabulum. 
The  gemellus  inferior  and  the  quadratus  femoris  had  been  torn,  the 
lio-amentum  teres  had  been  wholly  detached,  and  there  was  a  laceration 
in  the  lower  part  of  the  capsular  ligament.^ 

Dr.  Blackman,  of  Cincinnati,  informs  me  that,  in  Jan.  1859,  he  re- 
duced a  sub-cotyloid,  incomplete  dislocation,  in  a  man  ast.  70,  by 
manipulation,  Dr.  Judkins  lifting  the  thigh  upwards  and  outwards  by 
means  of  a  towel,  while  Dr.  Blackman  first  flexed  and  then  abducted 
the  limb. 


5.  Dislocations  Forwards  into  the  Perineum. 

Syn. — "Perineales;"  Malgaigne.  "Luxation  sur  la  branche  ascendante  de 
I'ischion;"  D'Amblard.     "  Inwards  on  the  ramus  of  the  os  pubis ;"  Skey. 

D'Amblard  published  an  example  of  this  accident  in  1821,  occa- 
sioned by  a  violent  muscular  exertion  made  by  the  patient  in  an  effort 
to  spring  into  his  carriage,  the  symptoms  attending  which  did  not 
differ  materially  from  those  which  were  found  to  be  present  in  the 
three  following  examples,  except  that  in  the  first  case  the  toes  were 
turned  slightly  inwards,  while  in  each  of  the  other  cases  they  were 
turned  outwards.^ 

Mr.  E ,  set.  35,  a  calker  by  occupation.  The  injury  was  re- 
ceived while  at  work  under  the  bottom  of  a  canal-boat,  July  20, 1831, 
the  boat  being  raised  upon  props  three  and  a  half  feet  long.  The 
patient  was  standing  very  much  bent  forwards,  with  his  feet  far  apart, 
between  which  lay  a  piece  of  round  timber  one  foot  in  diameter,  when 
the  props  gave  way,  letting  the  whole  weight  of  the  boat  upon  him- 
self and  his  companions.  One  of  the  workmen  was  killed  outright. 
On  extricating  Mr.  E.  from  his  situation,  the  left  leg  and  thigh  were 
found  extended  at  a  right  angle  with  the  body,  the  toes  turned  slightly 
inwards,  the  natural  form  of  the  nates  was  lost,  and  the  head  of  the 
femur  could  be  felt  distinctly  moving,  when  the  limb  was  rotated,  in 
the  perineum,  behind  the  scrotum,  and  near  the  bulb  of  the  urethra. 

For  the  purpose  of  reduction,  the  patient  was  laid  on  his  back 
upon  a  table,  and  the  pelvis  made  fast  by  a  muslin  band.  Extension, 
accompanied  with  moderate  rotation,  was  then  made  in  a  direction 

'  Luke,  Med.  News  and  Library,  vol.  xvi.  p.  34,  March,  1858  ;  from  Med.  Times 
and  Gaz.,  Jan.  2,  1858. 
2  Malgaigne,  op.  cit.,  torn.  ii.  p.  876. 


ANOMALOUS    DISLOCATIONS.  685 

outwards  and  downwards,  bringing  the  head  of  the  bone  over  the 
ascending  ramus  of  the  ischium,  beyond  which  it  was  lying,  into  the 
foramen  thyroideum  ;  and  from  this  position  the  bone  was  replaced  in 
the  acetabulum,  by  carrying  the  dislocated  limb  forcibly  across  the 
opposite  one.     The  patient  soon  recovered  the  use  of  the  joint.^ 

J.  B.,  an  Irishman,  set.  40,  on  entering  the  St.  Louis  hospital,  gave 
the  following  account  of  his  accident,  which  had  occurred  six  hours 
previously.  He  was  engaged  in  excavating  earth,  and  having  under- 
mined a  bank,  it  unexpectedly  fell  upon  his  back  while  he  was  stand- 
ing in  a  bent  position,  with  his  thighs  stretched  widely  apart.  The 
weight  crushed  him  to  the  earth,  breaking  both  bones  of  his  right  leg, 
the  radius  of  the  same  side,  and  dislocating  the  left  hip  into  the  peri- 
neum. The  thigh  presented  a  peculiar  appearance,  being  placed  quite 
at  a  right  angle  with  the  body,  but  somewhat  inclined  forwards.  The 
part  of  the  hip  naturally  occupied  by  the  trochanter  major  presented, 
a  depression  deep  enough  to  receive  the  clenched  fist ;  while  the  head 
of  the  bone  could  be  both  seen  and  felt  projecting  beneath  the  skin  of 
the  raphe  in  the  perineum.  Eotation  of  the  limb,  which  was  difficult 
and  excessively  painful,  rendered  the  position  of  the  head  still  more 
manifest.  The  patient  had  also  retention  of  urine,  occasioned  proba- 
bly by  the  pressure  of  the  femur  upon  the  urethra.  Having  dressed 
the  fractures,  Dr.  Pope  placed  the  patient  under  the  full  influence  of 
chloroform,  and  then  proceeded  to  reduce  the  dislocated  thigh;  for 
which  purpose  "  two  loops  were  applied,  interlocking  each  other  in 
the  groin,  and  using  the  leg  as  a  lever,  extension,  by  means  of  the 
pulleys,  was  made  transversely  to  the  axis  of  the  body.  A.  steady 
force  was  kept  up  for  a  short  time,  and  the  thigh-bone  glided  into  its 
socket  with  a  snap  that  was  heard  by  every  attendant  and  patient  in 
the  large  ward."^ 

A  man,  get.  22,  was  admitted  to  the  Toronto  Hospital,  under  the 
care  of  Dr.  B.  W.  Hodder,  Jan.  15,  1855,  having  been  injured  by  the 
fall  of  a  bank  of  earth  an  hour  before.  The  head  of  the  right  femur 
was  found  under  the  arch  of  the  pubes,  the  neck  resting  upon  the 
ascending  ramus.  The  thigh  formed  nearly  a  right  angle  with  the 
body  ;  it  was  also  strongly  abducted,  and  the  toes  were  slightly  everted. 
On  the  following  day,  the  patient  being  placed  under  the  influence  of 
chloroform,  extension  and  counter-extension  were  employed  in  the 
direction  of  the  axis  of  the  femur,  that  is,  nearly  at  right  angles  with 
the  body,  while,  at  the  same  moment,  the  upper  portion  of  the  femur 
was  lifted  by  a  round  towel.  By  this  manoeuvre  the  head  of  the  bone 
was  carried  into  the  foramen  thyroideum.  The  force  was  now  applied 
in  a  direction  "  more  upwards  and  outwards ;  the  ankle  held  by  the 
assistant  was  drawn  under  the  other  and  at  the  same  time  rotated." 
In  a  few  minutes  the  complete  reduction  was  accomplished.  His  re- 
covery has  been  steady,  and  three  weeks  later  he  was  discharged,  being 
able  to  walk  very  well  with  the  aid  of  a  cane.^ 

•  W.  Parker,  New  York  Med.  Gaz.,  1841;  N.  Y.  Journ.  Med.,  March,  1832,  p. 
188. 

2  Pope,  St.  Louis  Med.  and  Surg.  Journ.,  July,  1850;  N.  Y.  Journ.  Med.,  March, 
1853,  p.  198. 

"  Hodder,  British  Amer.  Journ.,  March,  1861. 


686  DISLOCATIONS    OF    THE    THIGH. 

§  6.  Ancient  Dislocations  of  the  Femur. 

Sajs  Sir  Astley  Cooper:  "I  am  of  opinion  that  three  months  after 
the  accident  for  the  shoulder,  and  eight  weeks  for  the  hip,  may  be 
fixed  as  the  period  at  which  it  would  be  imprudent  to  attempt  to  make 
the  reduction,  except  in  persons  of  extremely  relaxed  fibre  or  of  ad- 
vanced age.  At  the  same  time,  I  am  fully  aware  that  dislocations 
have  been  reduced  at  a  more  distant  period  than  that  which  I  have 
mentioned;  but  in  many  instances  the  reduction  has  been  attended 
with  the  evil  results  which  I  have  just  been  deprecating."  A  remark 
which  later  surgeons  do  not  seem  always  to  have  correctly  understood, 
or  which,  if  they  have  understood,  they  have  not  correctly  represented ; 
since  it  has  many  times  been  affirmed  of  this  distinguished  surgeon, 
that  he  regarded  reduction  of  the  hip  as  impossible  after  eight  weeks, 
and  they  have  proceeded  to  cite  examples  which  would  prove  that  he 
was  in  error.  But  long  before  Sir  Astley's  day,  Gockelius  mentioned 
a  case  of  reduction  of  the  femur  after  six  months,  and  Guillaume  de 
Salicet  declared  that  he  had  reduced  a  similar  dislocation  after  one 
year,^  and  Sir  Astley  says  that  he  is  "fully  aware"  of  the  existence  of 
such  facts;  yet  with  a- knowledge  of  what  has  so  frequently  followed 
these  attempts,  he  would  not  recommend  the  trial  after  eight  weeks, 
except  under  the  circumstances  by  him  stated;  and  notwithstanding 
the  number  of  these  reported  successes  has  been  considerably  increased 
in  our  day,  we  suspect  that  Sir  Astley's  rule  will  continue  to  govern 
experienced  and  discreet  surgeons.  Certain  examples  which  have 
recently  been  published  of  successful  reduction  after  six  months  by 
manipulation,  would  encourage  a  hope  that  the  period  might  be  greatly 
extended,  were  it  not  that  manipulation  also  has  already  failed  many 
times  in  the  case  of  ancient  luxations,  and  that  the  attempt  has  some- 
times been  followed  with  disastrous  results,  even  in  recent  cases. 

The  following  are  examples  of  reduction  by  manipulation  after  the 
lapse  of  six  months  : — 

On  the  21st  of  March,  1856,  a  man  presented  himself  at  the  Com- 
mercial Hospital,  Cincinnati,  with  a  dislocation  of  the  femur  upon  the 
dorsum  ilii,  of  six  months'  standing.  The  limb  was  shortened  two 
inches.  Dr.  Blackman,  under  whose  care  he  was  admitted,  adminis- 
tered chloroform,  and  by  manipulating  after  the  method  described  by 
Dr.  Eeid,  the  reduction  was  accomplished.^ 

In  a  letter  addressed  to  me  by  Dr.  Blackman,  and  dated  April  21st, 
1859,  he  informs  me  that  this  patient  presented  himself  again  before 
the  class  about  six  months  since,  and  the  restoration  of  the  functions 
of  the  limb  was  found  to  be  complete. 

The  second  example  occurred  in  the  practice  of  Martial  Dupierris, 
of  Havana,  Cuba.  A  Chinese  boy  named  A-sin,  aged  about  sixteen 
years,  arrived  at  Havana  on  the  fourth  of  June,  1856,  suffering  under 
a  severe  illness,  which  confined  him  for  a  month  or  more  to  his  bed, 

'  Malgaigne,  op.  cit.,  torn.  ii.  p.  185;  from  Gallicinium  Medico-practicum,  Ulm, 
1700,  p.  288. 
2  Blackmail,  Ohio  Med.  and  Surg.  Journ.,vol.  viii.  p.  522. 


ANCIENT    DISLOCATIONS    OF    THE    FEMUR.  687 

ancUthe  existence  of  the  dislocation  was  not  discovered  until  he  had 
sufficiently  recovered  to  rise  upon  his  feet.  It  was  then  ascertained 
that  he  had  a  dislocation  of  the  left  femur  upon  the  dorsum  ilii.  Upon 
inquiry,  Dr.  Dupierris  learned  that  the  accident  had  occurred  before 
leaving  China,  a  period  of  more  than  six  months.  The  boy  was  still 
feeble,  the  limb  somewhat  emaciated,  and  instead  of  being  rigid  from 
muscular  contraction,  all  the  muscles  "  were  in  a  flaccid  condition, 
except  the  great  gluteal,  which  was  painful  to  the  touch,"  Deeming 
the  use  of  aneesthetics  improper,  on  account  of  the  boy's  feeble  condi- 
tion, these  agents  were  not  employed.  Dr.  Dupierris  describes  the 
method  of  reduction  as  follows  :  "  The  body  being  held  by  two  assist- 
ants by  means  of  two  bands,  one  of  which  passed  beneath  the  peri- 
neum, and  the  other  under  the  axillae,  traction  was  made  upon  the 
limb  by  two  strong  and  intelligent  assistants.  The  movement  of  the 
head  of  the  bone,  resulting  from  this  manoeuvre,  was  very  limited, 
even  when  the  force  was  much  increased ;  and  the  excruciating  pain, 
which  the  patient  referred  to  the  iliac  region,  compelled  us  for  the 
moment  to  desist. 

"The  following  day,  the  patient  having  obtained  a  tolerable  night's 
rest  by  means  of  a  narcotic  potion,  I  concluded  to  attempt  the  reduc- 
tion by  flexion,  believing  that  I  could  thus  better  prevent  any  accident 
which  the  necessary  force  might  produce;  the  operator,  in  adopting 
this  method,  having  it  in  his  power  to  follow  the  head  of  the  bone  by 
pressure  upon  it  with  the  hand,  aiding  its  movement  in  the  proper 
direction,  or  correcting  any  deviation  that  may  occur.  The  emaciated 
condition  of  the  boy  was  eminently  favorable  for  such  a  procedure. 

"  The  patient  being  placed  upon  his  back,  and  the  trunk  of  the  body 
made  steady  by  assistants,  with  the  left  hand  I  grasped  the  upper 
part  of  the  leg,  placed  the  right  hand  upon  the  head  of  the  bone  in  the 
iliac  fossa,  and  then  proceeded  to  flex  the  leg  upon  the  thigh,  and  the 
thigh  upon  the  pelvis.  By  this  movement  the  great  gluteal  muscle 
was  relaxed,  and  the  head  of  the  bone  advanced,  while  with  the  right 
hand  I  directed  the  latter  toward  the  cotyloid  cavity.  As  soon  as  I 
judged  the  head  to  be  immediately  above  the  centre  of  the  socket,  I 
extended  the  lea:,  the  thigh  remaininsr  flexed  at  a  rio;ht  ansjle  ;  and 
then  using  the  limb  as  a  lever,  I  rotated  it  from  within  outwards,  and 
at  the  same  time  extended  it  by  making  a  movement  of  circumduc- 
tion in  a  similar  direction.  Whe  iby  these  procedures  the  limb  was 
brought  near  to  its  opposite  fallow,  a  snap  audible  to  the  assistants, 
and  of  a  deeper  character  than  is  ordinarily  observed  in  the  reduction 
of  recent  dislocations,  indicated  the  return  of  the  head  of  the  bone  to 
its  natural  position;  a  fact  which  was  further  substantiated  by  the 
establishment  of  the  original  length  and  form  of  the  member  and  the 
subsidence  of  the  pain. 

"  The  after-treatment  consisted  in  placing  a  pad  between  the  knees, 
and  another  between  the  internal  malleoli,  and  confining  the  limbs 
together  by  two  bands,  one  above  the  knees,  and  the  other  around  the 
lower  part  of  the  legs.  But  in  spite  of  these  precautions  to  prevent 
redisplacement,  the  next  morning  I  found  that  the  dislocation  had 
been  reproduced.     It  was  again  reduced,  but  for  three  successive  days 


688 


DISLOCATIONS    OF    THE    THIGH. 


there  was  a  redisplacement.  After  tins,  however,  the  head  of  the  bone 
kept  its  place;  passive  motion  was  daily  employed,  and  all  suffering 
ceased.  After  twenty  days  of  rest,  and  a  liberal  use  of  the  lactate  of 
iron,  the  patient  was  allowed  to  get  up;  and,  being  provided  with  a 
pair  of  crutches,  upon  which  he  exercised  himself  daily,  improved 
very  rapidly.  The  muscles  gradually  recovered  their  bulk  and  vigor, 
and  at  the  end  of  forty-eight  days  he  was  enabled  to  walk  without 
crutches,  although  with  some  fear  of  falling.  About  the  middle  of 
August  he  was  put  to  work  in  a  cigar  manufactory,  and  has  continued 
well  ever  since." 

The  third  is  a  case  reported  by  Dr.  A.  W.  Smyth,  of  New  Orleans. 
The  dislocation  was  upon  the  dorsum  ilii,  of  nearly  nine  months' 
standing;  and  it  was  reduced  by  manipulation,  in  the  first  attempt. 
The  reduction  was  accompanied  with  "  a  good  deal  of  snapping  and 
breaking." 

Dr.  Brown,  of  Boston,  has  published  an  interesting  case  of  reduction 
of  an  ancient  dislocation  of  the  hip  in  a  child  8  years  old.  He  believes 
the  dislocation  to  have  been  caused  by  rheumatic  arthritis.  In  the 
same  connection  he  has  furnished  a  table  of  the  cases  of  reduction  of 
ancient  dislocations  of  the  hip,  which  he  has  found  upon  record.'  I 
republish  the  table,  with  a  single  correction. 


SOR8EON. 

Time. 

AUTHORITT. 

Gockelius. 

180  days. 

Gallicinium  Med.  -praclicum,  p.  288. 

Salicet. 

365     " 

Ibid. 

Dupuytren, 

31     " 

Op.,  cliap.  19. 

(( 

78     " 

Ibid. 

a 

99     " 

a 

Dupierris. 

180     " 

Hamilton,  Frac.  and  Dis.,  p.  679. 

Breschet. 

72     " 

Eepertoire  Generale. 

Cooper. 

26     " 

Dislocations  and  Fractures,  p.  35. 

" 

5  years. 

Ibid.,  p.  81. 

Listen. 

35  days. 

Ibid.,  p.  45. 

2  years. 

Mem.  de  I'Acad.  Eoy.  de  Chir.  de  Paris,  torn 
V.  p.  529. 

Guillaiime  de  Salicet. 

365  days. 

Malgaigne,  tom.  ii.  p.  281. 

Hayward. 

Op.,  p.  71. 

Crosby. 

68    " 

Trans.  Am.  Med.  Assoc,  vol.  iii.  p.  356. 

Atlee. 

120     " 

Ibid.,  p.  357. 

Williams. 

150     " 

Lancet,  1862,  vol.  i.  p.  665. 

Bigelow. 

90     " 

Dis.  and  Fract.  of  Hip,  p.  211. 

(I 

240     " 

Ibid.,  p.  55. 

u 

28     " 

"     p.  54. 

Blackman. 

180     " 

Ohio  Med.  and  Surg.  Jour.,  vol.  viii.  p.  522. 

Smyth. 

270     " 

New  Orleans  Jour.  Med.,  January  1,  1869. 

Brown. 

105     " 

Kimball. 

90     " 

Northwestern  Med.  and  Surg.  Journal,  June 

1870.. 


In  the  comparison  of  the  relative  value  and  hazards  of  the  different 
modes  of  reduction,  I  have  cited  several  examples  of  fracture  of  the 
neck  of  the  femur  in  the  attempt  to  reduce  old  dislocations.  In  some 
cases  the  results  have  been  much  more  serious. 

A  man,  29  years  old,  was  received  at  La  Pitid,  Paris,  on  the  18th  of 


I 


'  Spontaneous  dislocation  on  dorsum  ilii.     Reduction  after  several  months.     By 
Francis  Brown,  M.D.,  Surgeon  to  the  Children's  Hospital,  &c.  &c.,  Boston. 


ANCIENT    DISLOCATIONS    OF    THE    FEMUE.  689 

May,  1868,  with  dislocation  of  the  hip  of  seven  months'  standing.  M. 
Broca  attempted  to  reduce  it,  using  a  force  of  480  lbs.  No  reduction 
was  obtained,  and  the  patient  insisted  upon  leaving  the  hospital  five 
days  afterward.  A  fortnight  then  elapsed,  when  he  presented  himself 
at  another  hospital,  with  the  hip  enormously  swollen,  and  died  the 
next  day  of  peritonitis.  The  autopsy  showed  that  the  head  of  the 
bone  lay  in  the  ischiatic  notch,  that  it  was  held  firmly  by  bundles  of 
the  torn  capsule,  and  that  the  cotyloid  cavity  was  much  shrunk.  Pus 
was  found  in  the  capsule,  in  the  iliac  fossa,  in  the  articular  cavities, 
and  had  found  its  way  into  the  peritoneum,  through  the  obturator 
foramen.^ 

The  following  case  seems  deserving  of  mention,  for  the  reason  that 
it  is  the  first,  so  far  as  I  am  aware,  in  which  an  attempt  has  been  made 
to  reduce  the  dislocation  after  a  subcutaneous  division  of  the  cap- 
sule : — 

Thomas  Jordan,  aet.  28,  of  Utica,  N.  Y.,  was  sent  to  me  by  my 
former  pupil.  Dr.  Jenkins,  in  January,  1869,  having  a  dislocation  of 
his  left  femur  upwards  and  backwards  upon  the  dorsum  ilii.  His 
account  of  the  case  was,  that  seven  months  before  he  was  thrown  in 
wrestling;  a  surgeon  was  called  on  the  following  day,  and  finding  a 
dislocation,  he  placed  him  under  the  influence  of  an  angesthetic,  and., 
as  he  supposed,  reduced  the  dislocation  by  manipulation. 

The  case  did  not  come  under  the  notice  of  Dr.  Jenkins  until  a  few 
weeks  before  he  was  sent  to  me,  and  although  the  character  of  the 
accident  was  recognized,  no  attempts  were  made  at  reduction. 

I  found  the  limb  rotated  inward,  adducted,  and  shortened  two 
inches.  Before  the  class  of  medical  students  at  Bellevue,  assisted  by 
Drs.  Sayre,  Crosby,  Howard,  and  others,  I  made  an  attempt,  January 
29th,  to  break  up  the  adhesions  and  reduce  the  dislocation,  the  patient 
being  fully  under  the  influence  of  ether.  We  were  able  to  move  the 
limb  quite  freely  in  various  directions ;  but  after  a  trial  of  nearly  an 
hour,  we  abandoned  the  attempt,  having  failed  to  accomplish  reduc- 
tion. 

A  few  days  later  I  applied  extension,  by  means  of  adhesive  plaster 
and  a  cord,  with  a  weight  of  twenty  pounds.  This  was  continued  un- 
remittingly until  February  the  24th,  when  he  was  again  placed  under 
the  influence  of  ether  before  the  class.  Assisted  by  Drs.  Stephen 
Smith,  Howard,  Cross,  and  others,  attempts  were  made  to  reduce  the 
bone  by  manipulation,  but  without  success.  Believing  now  that  the 
untorn  portion  of  the  capsule,  and  particularly  the  ilio-femoral  liga- 
ment, constituted  the  chief  obstacle  to  the  reduction,  I  introduced  a 
long,  firm,  but  narrow  bistoury,  which  I  had  had  made  for  the  purpose, 
just  above  the  trochanter  major,  carrying  its  point  inward  until  it 
touched  the  neck  at  the  base  of  the  trochanter.  From  this  point,  the 
edge  of  the  knife  being  directed  towards  the  head  of  the  bone,  I  swept 
the  point  of  the  knife  slowly  along  until  the  head  was  distinctly  felt, 
the  point  touching  the  neck  apparently  in  its  whole  length.  This  was 
accomplished  without  enlarging  the  external  opening.     While  the  in- 

»  New  York  Med.  Record,  Dec.  IG,  1868. 


690  DISLOCATIONS    OF    THE    THIGH. 

cision  was  being  made  the  limb  was  kept  rotated  outwards,  and  ab- 
ducted as  much  as  was  possible,  and  it  was  felt  to  yield  distinctly,  so 
that  both  rotation  outwards  and  abduction  were  more  complete  after- 
wards than  before.  I  then  divided  also  the  tensor  vaginae  femoris ; 
and  now  the  attempts  at  reduction  were  repeated,  both  by  manipula- 
tion and  extension,  but  without  success. 

The  result  of  this  attempt  to  reduce  the  dislocation  by  division  of 
the  ilio-femoral  ligament,  although  unsuccessful,  encourages  a  hope 
that  it  may  sometimes  succeed ;  and  I  shall  not  hesitate  to  repeat  the 
experiment,  if  a  favorable  opportunity  is  presented. 

§  1.  Partial  Dislocations  of  the  Femur. 

Malgaigne  declares  that  certain  experiments  made  upon  the  cadaver 
led  him,  at  one  time,  to  the  conclusion  that  all  primitive  luxations  of 
the  femur  were  incomplete,  and  that  the  old  complete  luxations  found 
in  autopsies  had  become  so  consecutively.  Later  observations  have 
taught  him  to  correct  this  error,  yet  he  still  finds  "incomplete  back- 
ward luxations  quite  common,  and  incomplete  dislocations  in  all  the 
other  directions  much  more  common." 

I  have  more  than  once  found  occasion  to  call  in  question  the 
accuracy  of  Malgaigne's  views  in  relation  to  partial  dislocations,  the 
relative  frequency  of  which  he  seems  constantly  disposed  to  greatly 
exaggerate.  We  cannot  see  the  propriety  of  calling  those' cases  par- 
tial dislocations,  in  which  the  head  of  the  bone  has  fairly  left  the  coty- 
loid cavity,  and  mounted  upon  its  margin,  even  if  it  remains  in  this 
position  without  tearing  the  capsule ;  since  the  articular  surfaces  are 
now  as  completely  separated  as  if  the  capsule  had  given  way,  and  the 
head  of  the  bone  had  escaped  through  the  laceration.  It  is  in  fact  a 
complete  luxation.  But  I  doubt  very  much  whether  the  head  of  the 
bone  ever  rests  upon  the  margin  of  the  acetabulum  without  tearing 
the  capsule,  unless  it  has  previously  undergone  certain  pathological 
changes,  such  as  I  have  already  described ;  at  least  I  cannot  hesitate 
to  reject  all  those  examples  in  which  the  head  of  the  femur  is  sup- 
posed to  rest  upon  the  upper  or  outer  margin  of  the  acetabulum  ;  and 
if  I  permit  myself  to  speak  of  incomplete  dislocations  at  all  in  this 
connection,  I  shall  reserve  the  term  for  those  rare  cases  in  which  the 
head  of  the  femur  becomes  engaged  in  the  cotyloid  notch,  after  break- 
ing down  the  fibrous  band  which,  in  the  natural  state,  is  continuous 
with  the  rim  of  the  acetabulum. 

Of  this  form  of  dislocation,  I  think  I  have  met  with  two  examples; 
one  of  which  was  in  the  person  of  the  boy  Lower,  already  mentioned, 
whose  thigh  was  reduced  accidentally  by  his  father ;  and  the  other 
occurred  in  a  boy  fifteen  years  of  age,  residing  at  that  time  in  Rutland, 
Vermont.  He  was  brought  to  me  on  the  28th  of  May,  184:2,  by  Dr. 
Ha3mes,  of  Rutland,  at  which  time  the  dislocation  had  existed  five 
years.  His  account  of  himself  was  that  in  walking  upon  a  slippery 
floor,  his  left  leg  slid  outwards  and  backwards  in  such  a  manner  as 
that  when  he  fell  it  was  fairly  doubled  under  his  back.  On  the  tenth 
day  following  the  accident  he  began  to  walk  with  some  help,  and  he 


COXO-FEMORAL    DISLO  C  ATIOISTS    WITH    FRACTURE.      691 

has  continued  to  walk  ever  since,  but  with  a  manifest  halt.  Three 
months  after  the  injury  was  received,  it  was  first  seen  by  several 
surgeons,  who  pronounced  it  a  dislocation,  and  attempted  reduction 
without  mechanical  aid,  but  were  unsuccessful. 

When  the  young  man  was  brought  to  me,  the  limb  was  neither 
lengthened  nor  shortened,  but  the  thigh  was  forcibly  abducted  and 
rotated  outwards.  It  could  not  be  flexed  nor  greatly  extended.  The 
bead  of  the  femur  could  be  distinctly  felt,  as  it  lay  anterior  to  the 
socket,  but  not  sufficiently  far  forwards  to  rest  upon  the  foramen 
ovale. 

J.  C.  Warren,  of  Boston,  has  reported  a  similar  example  in  a  child 
six  years  old,  who  was  brought,  April  21,  1841,  to  the  Massachusetts 
General  Hospital.  Dr.  Hale,  who  saw  the  lad  at  the  end  of  two  weeks, 
thought  it  a  dislocation,  but  it  had  been  treated  by  another  surgeon 
as  a  case  of  hip-disease.  The  dislocation  had  now  existed  eight  or 
ten  weeks.  The  limb  was  a  little  lengthened,  abducted,  turned  out- 
wards, and  advanced  in  front  of  the  body,  with  very  slight  motion  of 
either  flexion  or  extension,  and  almost  no  tenderness  about  the  joint. 
Dr.  Warren,  also,  was  able  to  feel  indistinctly  the  head  of  the  bone 
"immediately  external  to,  and  in  contact  with,  the  insertion  of  the 
triceps  and  gracilis  muscles." 

An  attempt  was  made  by  manual  extension  and  manipulation  to 
accomplish  the  reduction,  but  without  success.^ 

It  is  probable  that  both  the  above  cases,  which  I  have  described 
at  length,  were  examples  of  partial  dislocation ;  yet  I  cannot  conceal 
from  others  a  doubt  which  I  actually  entertain  whether  they  were 
not,  after  all,  only  examples  of  hip-joint  disease,  arrested  after  having 
wrought  certain  slight  pathological  changes  in  the  joint  and  the  tis- 
sues adjacent.  If,  however,  they  were  not  examples  of  incomplete 
dislocations  of  the  hip-joint,  then  I  question  whether  any  such  cases 
have  ever  occurred. 


§  8.  coxo-femoral  dislocations,  complicated  with  fracture  op  the 

Femur, 

Such  complications  are  exceedingly  rare,  but  it  will  not  do  to  deny 
their  possibility  ;  although  in  some  of  the  cases  reported,  the  testimony 
is  so  incomplete  as  to  leave  a  doubt  whether  the  surgeons  have  not 
erred  in  their  diagnosis. 

James  Douglas  has  reported  a  case  of  dislocation  upon  the  pubes, 
complicated  with  a  fracture  of  the  neck  of  the  femur,  the  actual  con- 
dition of  which  was  verified  by  an  autopsy ;  the  patient  having  died 
twelve  years  after  the  injury  was  received.  The  head  of  the  femur 
still  remained  above  the  pubes,  and  was  in  no  way  connected  with  its 
neck  or  shaft.  The  upper  end  of  the  femur  projected  in  the  groin, 
lying  upon  the  inside  of  the  femoral  artery  and  vein.  Many  other 
curious  pathological  changes  had  also  occurred.* 

'Warren,  Bost.  Med.  and  Surg.  .Tourn.,  vol.  xxiv.  p.  220. 

2  Amer.  Journ.  Med.  Sci.,  vol.  xxxiii.  p.  455,  from  Lond.  and  Edin.  Month.  Jouru. 
of  Med.  Sci. ,  Dec.  1843. 


692  DISLOCATIONS    OF    THE    THIGH. 

The  well-authenticated  examples  of  reduction  of  the  dislocation, 
where  the  femur  was  broken  also,  are  still  more  rare ;  and  several  of 
the  recorded  examples  which  my  researches  have  discovered,  need 
additional  confirmation. 

John  Bloxham,  of  Newport,  in  the  Isle  of  Wight,  claims  to  have 
reduced  a  dislocation  of  the  femur  on  the  pubes,  which  was  accom- 
panied with  a  fracture  of  the  thigh  a  little  above  its  middle.  The 
following  is  the  account  of  this  interesting  case  which  we  find  in  the 
London  Medico- Ohirurgical  i?eyfei^;,  copied  from  the  Medical  Gazette  of 
Aug.  24th,  1838.  We  regret  that  we  are  unable  to  see  the  account 
as  published  in  the  Gazette,  which  might  supply  some  circumstances 
important  to  a  full  appreciation  of  the  case  : — 

On  the  seventh  or  eighth  day  after  the  accident,  "  the  patient  was 
laid  on  his  back  upon  the  bed,  and  kept  in  that  position  by  means  of 
a  sheet  passed  across  the  pelvis  and  fastened  to  the  bedstead ;  another 
sheet  was  also  passed  over  the  left  groin,  and  secured  in  a  similar 
manner.  The  dislocated  and  fractured  limb  was  then  inclosed  in 
splints,  one  of  which  extended  up  the  back  of  the  thigh  as  far  as  the 
tuberosity  of  the  ischium.  Pulleys,  which  were  secured  to  a  staple  in 
the  ceiling,  placed  at  the  distance  of  a  foot  to  the  right  of  a  point 
vertical  to  the  patient's  navel,  were  then  attached  to  a  bandage  fastened 
round  the  splints  as  high  up  as  possible. 

"  The  foot  was  raised  with  the  knee  extended,  so  as  to  bring  the 
limb  nearly  to  a  right  angle  with  the  line  of  the  tackle,  when,  by 
drawing  gradually  on  the  cord,  in  the  course  of  about  ten  or  fifteen 
minutes  the  head  of  the  bone  was  rendered  movable,  and  was  brought 
considerably  more  forward.  I  then  began  to  press  on  the  head  of  the 
bone,  so  as  to  push  it  downwards,  whilst  the  pulleys  held  it  partially 
disengaged  from  the  pelvis.  In  a  few  minutes  the  head  of  the  bone 
passed  over  the  ridge  of  the  os  pubis,  and  I  then  directed  the  foot  to 
be  raised  a  little  higher,  which,  by  putting  the  gluteii  muscles  more 
upon  the  stretch,  was  calculated  to  render  them  more  efficient  in 
drawing  the  bone  into  its  proper  place.  By  this  manoeuvre,  the  head 
of  the  bone  was  drawn  backwards,  and  on  the  foot  being  more  elevated 
and  the  cord  slackened,  it  continued  to  recede  from  my  fingers  till 
the  trochanter  major  made  its  appearance  in  the  natural  situation,  and 
the  reduction  was  found  to  be  perfectly  complete. 

"Lest  the  head  of  the  bone  should  slip  backwards  on  the  dorsum 
ilii,  I  directed  an  assistant  to  apply  firm  pressure  during  the  latter 
part  of  the  process,  above  and  behind  the  acetabulum. 

"  The  apparatus  was  then  removed,  the  thigh  bound  up  in  short 
splints,  and  the  patient  laid  upon  a  double-inclined  plane.  No  symp- 
toms of  inflammation  appeared  afterwards  about  the  joint.  Passive 
motion  was  employed  at  the  end  of  a  week,  and  occasionally  repeated 
during  the  whole  reparatory  process."^ 

Without  intending  to  question  the  accuracy  of  the  statements  in 
this  case,  which,  in  the  main,  seem  to  bear  the  marks  of  credibility, 
we  must  express  our  surprise  that  so  little  difficulty  was  experienced 

»  Lond.  Med.-Chir.  Rev.,  vol.  xix.  p.  420,  Oct.  1833. 


COXO-FEMOKAL    DISLOC ATIOjSTS    WITH    FEACTURE.      693 

in  the  reduction  if  the  femur  was  actually  broken,  no  more,  indeed, 
than  is  usually  experienced  when  the  bone  is  not  broken ;  and  that 
Mr.  Bloxhara  was  able  to  employ  safely  passive  motion  at  the  end  of 
a  week. 

Charles  Thornhill  relates,  in  the  London  Medical  Gazette  for  July, 
1836,  a  case  of  fracture  of  the  femur  through  its  upper  third,  in  a 
man  aet.  40,  with  dislocation  into  the  ischiatic  notch ;  which  disloca- 
tion, he  assures  us,  was  reduced  at  the  end  of  six  weeks.  But  it  is 
much  more  probable  that,  instead  of  reducing  a  dislocation,  he  re- 
fractured  the  bone.  During  more  than  one  hour  and  a  half,  aided 
by  pulleys,  tractions  and  manipulations  were  made  in  almost  every 
direction. 

The  upper  part  of  the  thigh  was  lifted  witli  all  the  strength  of  one 
man  by  means  of  a  jack-towel ;  it  was  violently  rotated,  adducted, 
and  abducted.  Both  the  perineal  and  the  knee  band  gave  way,  from 
the  excess  of  the  force  employed ;  and,  finally,  the  head  of  the  femur 
resumed  its  place  with  an  audible  crash.  After  which  the  "limb  was 
of  nearly  equal  length  with  the  other;"  but  there  remained  an  "im- 
mense deposit"  around  the  acetabulum.' 

Malgaigne  says  that  M.  Eteve  found  a  poor  fellow  with  a  disloca- 
tion of  his  left  thigh  backwards,  a  fracture  near  its  middle,  a  penetra- 
ting wound  of  the  knee,  and  a  fracture  of  the  fibula  in  the  same  leg. 
Without  delay  he  proceeded  to  reduce  the  dislocation  by  directing  two 
assistants  to  support  the  body,  three  to  support  the  leg,  and  two  more 
to  make  extension  from  a  towel  tied  not  very  tightly  around  the 
thigh  above  the  fracture.  The  leg  was  then  extended  upon  the  thigh, 
and  the  thigh  flexed  upon  the  pelvis  until  it  was  at  a  right  angle  with 
the  body ;  and  after  a  gradual  extension  had  been  made  in  this  direc- 
tion, M.  Et^ve  pushed  with  all  his  strength  the  head  of  the  bone  into 
its  socket.  Of  which  case  Malgaigne  justly  remarks,  that  the  "exten- 
sion" practised  by  the  surgeon  was  only  imaginary.^  If  the  reduction 
was  accomplished  at  all,  it  was  by  manipulation  and  pressure. 

Finally,  Markoe  relates,  in  the  paper  to  which  we  have  already 
several  times  made  allusion,  the  case  of  a  boy  get.  8,  who  was  admit- 
ted into  the  New  York  City  Hospital  on  the  29th  of  June,  1853,  with 
a  compound  fracture  of  the  right  thigh,  a  simple  fracture  of  the  left, 
and  a  dislocation  of  the  head  of  the  right  femur  upwards  and  back- 
wards upon  the  dorsum  ilii. 

When  placed  upon  the  bed,  the  right  limb  lay  obliquely  across  the 
abdomen  of  the  boy,  with  the  foot  resting  against  the  axilla  of  the 
left  side.  "The  house-surgeon,  to  whose  care  the  case  fell  on  admis- 
sion, took  the  injured  limb  in  his  hands  and  very  carefully  carried  it 
over  the  abdomen  to  the  right  side,  and  then  adducted  it  and  brought 
it  down  toward  the  straight  position,"  during  which  procedure  the 
head  of  the  bone  is  supposed  to  have  resumed  its  place  in  the  socket.^ 

Such  is  the  account  furnished  of  the  symptoms  and  treatment  of 
this  extraordinary  case;  too  meagre,  certainly,  to  entitle  it  to  much 

'  Amer.  Journ.  Med.  Sci.,  vor.'xxv.  p.  218. 

2  Malgaigne,  op.  cit.,  torn.  ii.  p.  206;  from  Gazette  Med.,  1838,  p.  757. 

3  New  York  Journ.  Med.,  Jan.  1855,  p.  30. 


694  DISLOCATIONS    OF    THE    THIGH. 

confidence,  or  to  permit  us  to  draw  from  it  any  practical  inferences. 
We  are  not  even  informed  what  was  tlie  name  of  the  young  man  who 
alone  saw  and  treated  the  case,  nor  what  was  his  responsibility  as  a 
surgeon. 

I  have  been  unable  to  find  any  other  examples  of  fracture  of  the 
femur  complicated  with  dislocation  ;  and,  rejecting  at  least  Mr.  Thorn- 
hill's  case  as  altogether  incredible,  the  proper  conclusion  would  be, 
that  reduction  is  sometimes  possible  m  recent  cases,  if  the  surgeon 
will  resort  promptly,  before  swelling  and  muscular  contractions  have 
taken  place,  to  manipulation  combined  with  pressure  upon  the  head 
of  the  bone.  Indeed,  it  is  probable  that  pressure  alone  is  the  means 
upon  which  the  success  will  finally  depend.  Richet  says  that  he  has 
several  times  dislocated  the  femur  in  the  cadaver;  and  then,  having 
sawn  off  the  head  so  as  to  represent  a  fracture,  he  has  always  been 
able  to  push  the  head  of  the  bone  easily  into  its  socket.^  By  seizing 
the  moment  then  when  the  patient  is  laboring  under  the  shock,  or  by 
placing  him  completely  under  the  influence  of  an  anassthetic,  no  re- 
sistance will  be  offered  by  the  muscles  any  more  than  in  the  cadaver, 
and  the  reduction  may,  perhaps,  be  easily  effected. 

I  have  no  confidence  that  anything  can  be  accomplished  by  exten- 
sion ;  nor  do  I  think  it  will  be  best  to  wait  until  the  femur  has  united, 
since  such  delay  will  probably  render  the  reduction  impossible. 

§  9.  Voluntary  Dislocations  of  the  Femur. 

Examples  in  which  persons,  having  suffered  no  disease  of  the  hip- 
joint,  have  been  able  voluntarily  to  dislocate  the  femur,  have,  from 
time  to  time,  been  recorded,  but  I  am  not  aware  that  any  dissections 
have  ever  been  made  in  these  cases.  I  shall,  therefore,  not  attempt 
any  explanation  of  the  facts,  but  simply  record  them  as  matters  of 
curious  interest,  and  for  the  purpose  of  inducing  others  to  make  of 
them  a  subject  of  investigation. 

Sir  Astley  Cooper  mentions  the  case  of  a  man  who  could  throw 
out  the  head  of  the  thigh-bone  at  pleasure,  and  reduce  it  with  equal 
facility.  A  similar  case  is  alluded  to  by  Samuel  Cooper,  in  his  First 
Lines.  Gibson  mentions  a  case  reported  by  Dr.  Lewis,  of  North  Caro- 
lina.- Dr.  Bigelow  has  seen  two  cases,  both  of  which  were  dorsal. 
Dr.  Moore,  of  Rochester,  has  furnished  an  account  of  the  case  of  John 
Parker,  whose  leg  was  first  partially  dislocated  at  Drury's  Bluff)  May 
13,  1864,  and  which  was  at  the  time  reduced  by  his  companions.  The 
accompanying  illustrations  (Figs.  304,  305)  were  obtained  from  photo- 
graphs, and  indicate  the  position  of  his  limb  when  a  voluntary  sub- 
luxation upon  the  dorsum  existed. 

The  following  case  was  reported  to  me  in  1865,  by  John  M.  For- 
rest, M.D.,  of  Portland,  Maine,  to  whom  the  man  presented  himself  as  a 
"  substitute,"  while  Dr.  Forrest  was  in  the'  service  of  the  U.  S.  Army. 
The  application  was  rejected. 

'  New  York  Journ.  Med.,  March,  1854,  p.  393;  from  Bullet,  de  Ther. 
2  Gibson's  Surgery,  vol.  i.  p. 367,  6tli  ed. 


VOLUNTARY    DISLOCATIONS    OF    THE    FEMUE. 


695 


"  Wm.  G.  Gliddon,  set.  37,  farmer,  says  that  he  has  been  able  to  dis- 
locate and  replace  the  femur  at  the  left  hip-joint  since  he  was  a  boy. 
It  is  not  the  result  of  any  injury  or  disease,  so  far  as  he  knows.  He 
is  in  good  health,  and  his  muscular  development  is  complete.  He 
accomplishes  the  dislocation  by  throwing  the  weight  of  his  body  upon 


Fiir.  304. 


Fi?.  30o. 


Voluntary  subluxation  upon  the  dorsum  ilii.     (From  Bigelow.) 

the  left  leg,  and  then  contracting  certain  muscles  about  the  hip.  The 
reduction  is  generally  more  difficult  than  the  dislocation,  sometimes 
requiring  the  aid  of  his  hand.  When  the  head  of  the  bone  is  out, 
there  is  a  marked  projection  above  and  behind  the  trochanter  major, 
apparently  caused  by  the  pressure  of  the  head  in  this  situation ;  the 
limb  is  very  slightly  if  at  all  everted;  while  out  of  place  it  causes 
pain ;  and  after  a  few  repetitions  the  pain  becomes  so  great  as  to  com- 
pel him  to  desist.  The  limb  was  not  measured  while  it  was  dislo- 
cated.    When  the  limb  is  in  position  he  does  not  walk  lame." 

The  following  is  the  only  case  which  has  come  under  my  personal 
observation:  Dr.  Wm.  G.  S.,  set.  24,  received  an  injury  on  the  out- 
side of  the  right  knee,  in  Feb.  1862,  from  the  kick  of  a  horse.  There 
was  no  apparent  injury  of  the  hip.  On  the  fourteenth  day  after  the 
accident  he  rode  forty  miles  on  horseback,  which  was  followed  by  some 
stiffness  in  the  right  hip.  Two  weeks  later,  in  mounting  his  horse,  he 
felt  something  slip  in  the  hip-joint.  From  that  day  until  this,  a  period 
of  four  years,  he  has  been  able  to  reproduce  the  same  slipping  volun- 
tarily, and  which  phenomenon  I  recognize  as  a  dislocation  upwards 
and  backwards.      I  have  examined  him  more  than  once,  and  he  has 


696  DISLOCATIONS    OF    THE    PATELLA. 

dislocated  and  reduced  the  dislocation  in  my  presence  repeatedly. 
Planting  his  right  foot  firmly  upon  the  floor  a  little  in  advance  of  the 
left,  with  his  toes  turned  out,  he  throws  his  weight  upon  the  right 
leg  by  carrying  his  pelvis  well  over  to  the  right,  and  then  contracts 
powerfully  the  gluteal  muscles.  Instantly  the  head  leaves  the  socket, 
and  seems  to  mount  upon  the  dorsum ;  the  trochanter  major  becomes 
rotated  inwards,  causing  a  slight  inward  rotation  of  the  leg  and  foot. 
He  can  do  the  same  when  lying  on  his  back,  but  not  with  the  same 
ease.  Eeduction  is  accomplished  without  change  of  position,  but 
by  what  precise  manoeuvre  I  have  not  determined.  The  reduction  is 
more  quiet,  and  less  sudden,  apparently,  than  the  dislocation.  Both 
manoeuvres  are  accompanied  with  some  pain.  He  is  not  lame,  nor 
does  the  dislocation  take  place  without  his  volition.  I  have  seen  one 
case,  also,  which,  although  pathological  in  character,  was  nevertheless 
caused  by  an  early  injury,  and  as  such  may  properly  be  noticed  in 
this  connection. 

Dr.  0.  Gillett,  »t.  65  (1867),  of  Westernville,  Oneida  Co,  N.  Y.,  was 
injured  in  his  left  hip-joint  when  16  years  old,  by  lifting  a  heavy 
weight.  He  felt  at  the  moment  something  give  way  in  the  joint,  and 
he  has  been  lame  ever  since;  at  first  he  was  quite  lame,  but  after  a  time 
the  soreness  about  the  joint  diminished,  and  up  to  within  about  three 
years  the  lameness  was  chiefly  due  to  a  lack  of  development  in  the 
limb.  Since  then  the  joint  has  again  become  tender,  and  during  the 
last  nine  months  he  has  been  able  to  throw  the  head  of  the  bone  out 
of  the  socket,  backwards  and  upwards.  Indeed,  the  bone  is  dislocated 
whenever  he  sits  down,  and  resumes  its  place  again  when  he  stands 
up.  It  is  quite  apparent  that  the  upper  and  outer  margin  of  the 
acetabulum  is  partly  absorbed  ;  and  probably,  also,  the  head  and  neck 
of  the  femur  are  in  some  measure  deformed  and  absorbed.  The  dislo- 
cation is  apparently  incomplete ;  and  while  it  exists  the  thigh  is  ab- 
ducted, and  slightly  rotated  outwards.  This  abduction  and  outward 
rotation  does  not  properly  belong  to  a  dislocation  upon  the  dorsum  of 
the  ilium,  but  as  the  condition  of  the  joint  and  of  the  adjacent  muscles 
is  abnormal,  it  will  not  require  to  be  explained. 


CHAPTER   XVII. 

DISLOCATIONS  OF  THE  PATELLA. 

§  1.  Dislocations  of  the  Patella  Outwards. 

Causes. — In  the  majority  of  caises  it  has  been  occasioned  by  muscu- 
lar action ;  and  especially  is  this  liable  to  occur  in  persons  who  are 
knock-kneed,  or  whose  external  condyles  have  not  the  usual  promi- 
nence anteriorly.  It  may  be  caused  by  suddenly  twisting  the  thigh 
inwards  while  the  weight  of  the  body  rests  upon  the  foot,  and  the  leg 
is  thus  kept  turned  outwards  ;  or  by  falling  with  the  knee  turned 
inwards  and  the  foot  outwards.     Occasionally  it  is  the  result  of  a  blow 


DISLOCATIOXS    OF    THE    PATELLA    OUTWARDS. 


697 


Fiir 


received  upon  the  inside,  or  upon  the  front  and  inner  margin  of  the 
patella.  In  some  persons  there  seems  to  exist  a  preternatural  laxity 
of  the  ligamentum  patellae  or  of  the  tendon  of  the  quadriceps  extensor, 
which  exposes  the  subject  to  this  accident  from  very  trifling  causes. 
Fergusson  says  he  has  known  it  to  be  occasioned  by  a  child's  stepping 
upon  the  knee  of  a  person  lying  in  bed ;  and  Skey  says  he  has  seen 
two  cases  which  occurred  spontaneously  during  sleep.  B.  Cooper  has 
seen  a  young  lady  who  frequently  dislocated  her  patella  outwards  by 
merely  striking  her  toe  against  the  carpet,  or  in  dancing.  Boyer,  Sir 
Astley  Cooper,  and  others  mention  similar  examples. 

Pathological  Anatomy. — Most  frequently  the  dislocation  is  only  par- 
tial, the  inner  half  of  the  patella  resting  upon  the  articular  surface  of 
the  outer  condyle ;  and  in  consequence  of  the  peculiar  obliquity  of 
these  surfaces,  together  with  the  actiou  of  the  vasti  and  rectus  femoris, 
the  outer  margin  of  the  patella  becomes  tilted  forwards. 

If  the  dislocation  is  more  complete,  this  margin  begins  to  fall  over 
backwards,  as  in  the  accompanying  drawing;  and  in  more  extreme 
cases  the  patella  lies  flat  upon  the  outer  side  of  the  condyle,  with  its 
inner  margin  directed  forwards. 

When  the  dislocation  is  partial,  it  is  "probable  that  neither  the  cap- 
sule nor  the  ligamentum  patellse  usually  suffers  much  laceration  ;  but 
in  complete  dislocations  the  capsule  at  least  must 
have  given  way  more  or  less.  Norris,  of  Philadel- 
phia, reports  a  case  of  partial  luxation  in  which  the 
complications  were  more  serious.  John  Scanlin,  set. 
82,  was  admitted  to  the  Pennsylvania  Hospital,  on 
the  27th  of  August,  1839,  in  consequence  of  injuries 
received  a  short  time  previous  by  having  become 
entangled  in  machinery.  In  addition  to  several  frac- 
tures in  other  limbs,  he  was  found  to  have  a  subluxa- 
tion of  his  left  patella  outwards,  its  outer  edge  being 
much  raised,  and  resting  on  the  side  of  the  external 
condyle  of  the  femur,  while  its  inner  edge  was  de- 
pressed, and  firmly  fixed  in  the  hollow  between  the 
condyles.  The  internal  lateral  ligament  of  the  knee 
was  ruptured,  allowing  the  head  of  the  tibia  to  be 
moved  considerably  outwards.  A  depression  existed, 
also,  between  the  tubercle  of  the  tibia  and  the  lower 
end  of  the  patella,  at  the  middle  and  inner  side  of 
the  knee,  evidently  produced  by  a  rupture  of  the  liga- 
mentum patella  in  nearly  its  whole  extent.  There 
was  almost  no  swelling,  and  the  limb  was  moderately  flexed.  By  firm 
pressure  the  patella  could  be  restored  to  position,  but  as  soon  as  the 
hand  was  removed  it  returned  to  its  original  position.  At  the  end  of 
two  months  "a  good  degree  of  motion  existed  at  the  knee-joint,  which 
was  in  no  way  inflamed  or  painful."^ 

Symptoms. — The  limb  is  slightly  bent,  but  immovable ;  the  breadth 
of  the  knee  is  considerably  increased;  the  inner  condyle  projects  un- 


Bislocatioa  of  the  pa- 
tella outwards. 


'  Norris,  Amer.  Joiirn.  Med.  Sci.,  vol.  xxv.,  Feb.  1840,  p.  276. 
45 


698  DISLOCATIOXS    OF    THE    PATELLA. 

naturally,  and  the  patella  is  distinctly  felt  upon  the  outer  side.  If  the 
dislocation  is  partial,  the  outer  margin  of  the  patella  forms  an  irregular 
sharp  ridge  in  front  of  the  external  condyle.  If  it  is  complete,  the 
inner  margin  presents  itself  in  front  of  the  external  condyle,  and  the 
outer,  margin  looks  backwards.  Usually  the  patient  suffers  great  pain 
as  long  as  the  dislocation  remains  unreduced, 

Watson,  of  New  York,  saw  a  case  of  complete  dislocation  of  the 
patella  outwards  in  a  fat  young  lady  with  lax  fibre,  and  occasioned 
by  dancing.  He  says  the  knee  was  slightly  but  firmly  flexed.  It 
was  reduced  by  a  very  slight  pressure  with  the  fingers,  and  although 
some  inflammation  with  effusion  into  the  joint  ensued,  the  use  of  the 
limb  was  completely  restored  in  a  week  or  ten  days,^ 

Prognosis. — Eeduction  is  in  general  easily  accomplished,  but  a  re- 
luxation  is  very  prone  to  occur.  In  the  few  examples  reported  of  a 
permanent  luxation,  the  patients  have  eventually  recovered  the  use  of 
the  limb  in  a  great  measure.  Boyer  saw  four  cases  of  this  kind,  in 
three  of  which  it  existed  in  the  left  leg,  and  had  remained  from  in- 
fancy. The  patellas  were  easily  replaced,  but  unless  confined  they 
soon  became  displaced  again ;  not  one  of  them  found  it  necessary  to 
apply  for  surgical  aid,  as  "  they  suffered  no  great  inconvenience  from 
the  luxation,  and  it  exempted  them  from  military  service." 

After  reduction,  very  little  or  no  inflammation  usually  follows. 
Mr.  Key  has,  however,  narrated  a  case  in  Ginjs  Hospital  Beports,  of 
death  from  suppuration  in  the  knee-jf)int,  following  upon  the  reduction 
of  an  inward  subluxation.  The  dislocation  was  produced  by  a  fall 
while  carrying  a  pail,  and  was  reduced  by  very  gentle  pressure;  but 
the  patient,  a  girl  get.  20,  although  apparently  in  good  health,  was 
believed  to  be  somewhat  strumous.^ 

Treatment. — In  order  to  relax  completely  the  quadriceps  extensor, 
by  whose  action  chiefly  the  patella  is  held  in  its  unnatural  position, 
the  body  should  be  bent  forwards,  while  at  the  same  moment  the  leg 
is  extended  upon  the  thigh  and  the  thigh  flexed  upon  the  body.  The 
surgeon  will  accomplish  these  indications  in  the  most  simple  manner 
by  placing  the  patient  in  a  chair  and  then  lifting  the  foot  upon  his 
own  shoulder,  as  he  kneels  or  sits  before  him.  Sometimes  the  patella 
will  resume  its  position  at  once  when  this  manoeuvre  is  adopted;  but 
if  it  does  not,  slight  lateral  pressure,  made  with  the  fingers,  will  gene- 
rally be  found  sufficient  to  accomplish  the  reduction. 

A  man,  set.  27,  was  sitting  on  a  box,  and  in  jumping  off*  tripped  him- 
self with  his  right  leg,  causing  a  partial  dislocation  of  the  patella  of 
the  left  leg  outwards.  Half  an  hour  after  the  receipt  of  the  injury  I 
found  him  sitting  with  the  knee  bent,  and  in  great  pain.  The  patella 
lay  upon  the  outer  half  of  the  articular  surface,  with  its  outer  margin 
a  little  tilted  upwards.  Lifting  the  leg  and  thigh  to  a  right  angle 
with  the  body,  and  making  vqtj  slight  pressure  upon  the  outer 
margin  of  the  patella,  it  immediately  resumed  its  place.  Very  little 
inflammation  ensued, 

'  AVatson,  New  York  Journ.  Med.,  vol.  i.  p,  306. 
2  Op.  cit.,  vol.  i.  p.  2G0. 


DISLOCATIONS    OF    THE    PATELLA    UPON    ITS    AXIS.      699 

In  some  instances,  where  other  means  have  failed,  the  reduction 
has  been  effected  by  violent  flexion  and  extension  of  the  knee,  aided 
by  lateral  pressure. 

I  have  already  mentioned,  when  speaking  of  dislocations  into  the 
foramen  thyroideum,  the  case  of  N.  Smith,  in  whose  person  I  found  at 
the  same  moment  a  dislocation  of  the  thigh,  a  subluxation  outwards 
of  the  tibia,  and  a  complete  outward  luxation  of  the  corresponding 
patella.  This  was  occasioned  by  a  fall  from  a  height  upon  the  inside 
of  the  knee.  I  reduced  the  tibia  first,  and  then  easily  replaced  the 
patella  by  lifting  the  leg  and  pushing  with  my  fingers  against  its  outer 
margin. 

In  many  cases  the  patients  themselves  have  reduced  the  dislocation 
immediately,  and  the  surgeon  is  only  consulted  in  relation  to  the  after- 
treatment.  Liston  says  that  this  is  so  constantly  the  fact,  or  else  such 
dislocations  are  really  so  rare,  that  it  has  never  happened  to  him  to 
have  an  opportunity  of  reducing  any  form  of  dislocation  of  the  patella. 

Not  long  since,  a  young  gentleman  set.  25,  residing  in  Somerset,  N.  Y., 
called  upon  me  in  consequence  of  having  discovered  a  floating  carti- 
lage in  his  knee-joint.  His  account  of  the  matter  was  that  on  the  first 
of  February,  1858,  he  was  kicked  by  a  cow  upon  the  outside  of  the 
right  leg,  about  six  inches  below  the  knee,  and  that  he  immediately 
found  the  patella  dislocated  outwards.  After  several  efforts,  he  finally 
succeeded  in  reducing  it  himself.  His  knee  soon  became  greatly 
swollen,  so  that  for  five  weeks  he  was  unable  to  walk,  and  he  has  been 
more  or  less  lame  to  this  time.  Six  months  after  the  accident  he  dis- 
covered a  floating  cartilage  on  the  inside  of  the  patella,  about  one  inch 
in  diameter,  which  occasionally  slips  between  the  joint  surfaces,  and 
suddenly  trips  him  up. 


§  2.  Dislocations  op  the  Patella  Inwards. 

Causes. — Less  frequent  than  dislocations  outwards, 
they  are  occasioned  generally  by  direct  blows  re- 
ceived upon  the  outer  margin  of  the  patella. 

The  symptoms,  pathological  anatomy,  and  treat- 
ment will  be  the  same  as  in  dislocations  outwards, 
except  so  far  as  these  must  necessarily  vary  from  the 
opposite  position  of  the  patella. 

S  3.  Dislocations  of  the  Patella  upon  its  Axis. 


Syn. — "  Semi-rotation ;" 
Malgaigne. 


Miller.      "Luxation   Verticale;' 


These  accidents,  of  which  I  have  found  recorded 
eighteen  examples,  seem  to  be  the  result  of  the  same 
causes  which  produce  lateral  luxations ;  and,  indeed, 
they  may  be  regarded  as  only  exaggerated  forms  of 
incomplete  lateral  dislocations.  In  these  latter  acci- 
dents, as  we  have  already  noticed,  the  external  or 
the  internal  margin  of  the  patella,  according  as  the 


Flo-.  307. 


Dislocatioa    of 
patella  inwards. 


700  DISLOCATIONS    OF    THE    PATELLA. 

subluxation  is  to  the  outer  or  inner  side,  is  thrown  more  or  less  ob- 
liquely forwards ;  a  position  into  which  it  is  carried  partly  by  the 
peculiar  form  of  the  articulating  surfaces,  and  partly  by  the  action  of 
the  vasti  and  rectus  femoris  muscles.  If  now  these  muscles  were  to 
contract  suddenly  and  violently,  and  the  return  of  the  patella  to  its 
normal  position  were  prevented  by  the  lodgement  of  one  of  its  margins 
in  the  inter-condyloidean  fossa,  the  other  or  free  margin  would  be 
compelled  to  rise  until  it  became  perpendicular  to  the  limb,  or  it 
might  perhaps  even  become  completely  reversed  in  its  socket.  The 
signs  of  the  accident  are  such  as  to  render  an  error  in  the  diagnosis 
almost  impossible.  The  limb  is  generally  found  forcibly  extended, 
occasionally  it  is  in  a  position  of  moderate  flexion,  but  the  projection 
of  the  sharp  border  of  the  patella  directly  forwards  under  the  skin  is 
itself  sufficient  to  determine  the  true  nature  of  the  injury. 

Eeduction  may  be  effected  by  the  same  manoeuvres  which  we  have 
recommended  in  lateral  luxations;  but  if  these  measures  do  not  suc- 
ceed, we  may  direct  the  patient  to  make  a  violent  eflbrt  himself  to 
flex  and  extend  the  limb,  or  the  surgeon  may  force  the  limb  into 
flexion  and  extension  alternately,  or  he  may  rotate  the  tibia  upon  the 
femur,  and  then  flex.  Finally,  he  ought  to  make  use  of  lateral  pres- 
sure also,  upon  both  margins  of  the  upright  patella,  but  in  opposite 
directions. 

Watson,  of  New  York,  has  related  the  following  example  of  rota- 
tion of  the  patella  upon  its  inner  margin  (" Luxation  Verticale  Externe," 
Malg)'. — 

Henry  Burton,  aged  about  thirty-five  years,  of  rather  slender  frame, 
while  riding  on  horseback  in  a  crowd,  received  a  blow  upon  his  knee 
from  a  horse  ridden  by  another  person.  When  seen  by  Dr.  Watson, 
soon  after  the  accident,  the  leg  w^as  perfectly  straight,  but  could  be 
flexed  to  about  an  angle  of  140°  without  causing  pain.  "  The  patella 
appeared  to  be  slightly  drawn  up,  and  it  was  twisted  upon  its  axis, 
presenting  its  outer  edge,  in  a  prominent  hard  line,  in  front  of  the 
knee;  its  inner  edge  was  resting  either  in  the  groove  between  the 
condyles  of  the  femur,  upon  which  its  posterior  face  should  naturally 
play,  or  in  the  small  depression  on  the  anterior  face  of  the  femur, 
immediately  above  this  groove.  The  anterior  surface  of  the  patella 
was  turned  inwards,  its  posterior  surface  outwards,  and  it  rested  nearly 
at  right  angles  with  its  natural  position.  Its  upper  and  lower  attach- 
ments were  both  preserved,  and  could  be  distinctly  felt ;  and  a  sort  of 
band  appeared  to  pass  from  its  under,  or,  as  it  now  lay,  its  outer  face, 
inwards  to  the  deeper  portion  of  the  knee-joint.  This  band,  as  I  con- 
ceived, was  caused  either  by  the  tension  of  the  capsular  ligament,  or 
by  the  rupture  of  its  edge,  as  it  passes  from  the  outer  side  of  the 
patella.  The  position  of  the  bone  was  so  well  marked  that  no  one  at 
all  acquainted  with  the  anatomy  of  the  part  could  mistake  the  nature 
of  the  accident. 

"With  the  leg  extended,  and  the  anterior  muscles  of  the  thigh 
forced  downwards  as  much  as  possible,  pressure  was  made  upon  the 
patella,  with  the  expectation  of  forcing  down  its  prominent  edge.  The 
efibrt  was  followed  only  by  an  increase  of  pain,  the  bone  remaining 


DISLOCATIONS    OF    THE    PATELLA    UPON    ITS    AXIS.      701 

permanently  fixed.  Another  attempt  was  made  to  cant  its  posterior 
edge  inwards,  and  to  bring  its  anterior  edge  outwards,  without  press- 
ing it  against  the  condyles  of  the  femur,  by  forcing  the  head  of  a  key 
against  the  posterior,  now  the  outer,  face  of  the  patella  (using  this  as 
a  fulcrum),  and  pressing  the  prominent  edge  of  the  bone  toward  the 
outer  condyle.  This  manoeuvre  gave  him  no  pain,  but  was  as  fruitless 
in  its  result  as  the  other.  At  length  the  knee  was  forcibly  bent  and 
immediately  straightened  again ;  and  then,  by  canting  the  patella  as 
before,  and  pushing  it  slightly  downwards  and  inwards,  it  sprung  with 
a  sudden  snap  into  its  proper  position,"^ 

Dr.  Joseph  P.  Gazzam,  of  Pittsburg,  Pa.,  has  met  with  a  similar 
case.  On  the  10th  of  Sept.  1842,  James  Porter  was  thrown  while 
wrestling,  and  immediately  found  himself  unable  to  rise.  Dr.  Gazzam 
saw  him  about  an  hour  after  the  accident,  and  found  the  patella  of  the 
right  leg  dislocated  on  its  axis,  and  resting  on  its  inner  edge  in  the 
groove  between  the  condyles  of  the  femur.  Dr.  G.  proceeded  to  at- 
tempt reduction,  but  failed,  after  having  made  repeated  trials  by  lift- 
ing the  limb  toward  the  body  and  by  pressure  in  opposite  directions. 
In  consultation  with  Dr.  Addison,  it  was  now  determined  to  divide 
the  ligamentum  patel]a3,  which  was  done  by  introducing  beneath  the 
skin  a  narrow-bladed  knife,  and  cutting  close  to  the  tubercle  of  the 
tibia.  Again  the  attempts  at  reduction  were  renewed,  but  without 
success.  The  patella  could  be  moved  on  its  edge  more  freely  than 
before  the  cutting,  but  resisted  every  effort  to  replace  it.  The  patient 
was  now  bled  in  the  erect  posture  and  until  the  approach  of  syncope, 
but  to  no  purpose.  On  the  following  morning  it  was  determined  to 
adopt,  with  some  modification,  the  mode  practised  so  successfully  by 
Dr.  Watson.  "The  thigh  was  strongly  flexed,"  says  Dr.  Gazzam,  "on 
the  pelvis,  and  the  heel  elevated.  Then  the  leg  was  flexed  steadily 
and  forcibly  on  the  thigh,  and  suddenly  straightened.  At  the  moment 
of  straightening  the  leg,  I  pressed  very  strongly  against  the  lower 
edge  of  the  patella  from  without,  with  the  head  of  a  door  key  well 
wrapped,  while  Dr.  Addison  pressed  with  both  thumbs  against  the 
upper  edge  of  the  bone  toward  the  external  condyle.  On  the  fourth 
trial  this  manoeuvre  succeeded,  the  bone  springing  into  its  place  with 
a  snap."  Eecovery  was  uninterrupted,  and  two  or  three  months  after, 
the  patient  had  the  complete  use  of  his  limb.^ 

The  following  case  is  reported  by  Dr.  S.  F.  Morris,  New  York: — 

"Mr.  B.,  aged  27,  of  slender  build,  while  playing  at  ball,  in  endeavor- 
ing to  strike  the  ball  had  to  jump  up  and  turn  partially  round,  when, 
on  resuming  his  former  position,  he  fell,  his  leg  refusing  to  bend.  He 
appreciated  the  nature  of  his  injury,  and,  with  the  aid  of  the  men  in 
the  store,  endeavored  to  'push  it  back.'  Failing  in  this,  surgical  aid 
was  sought,  but,  despite  three  attempts  at  reduction,  the  patella  re- 
mained displaced.     He  was  then  taken  to  his  home. 

"I  saw  him  about  two  hours  after  the  accident.  He  complained  of 
severe  pain  when  any  manipulation  was  made.    The  leg  was  perfectly 

>  Watson,  New  York  Journ.  Med.,  Oct.  1839,  p.  302. 

2  Gazzam,  Amer.  Journ.  Med.  Sci.,  vol.  xxxi.,  April,  1843,  p.  363. 


702  DISLOCATIONS    OF    THE    PATELLA. 

straight.  The  patella  was  firmly  wedged  (its  outer  edge)  in  the  inter- 
condyloid  fossa;  its  anterior  surface  looking  outwards  and  slightly 
downwards,  its  posterior  face  looking  inwards  and  upwards.  The 
prominence  of  the  edge  of  the  patella,  thus  twisting  on  its  longitudinal 
axis,  left  no  doubt  as  to  the  diagnosis. 

"No  attempt  was  made  at  reduction  by  me  until  the  patient  was 
etherized,  when,  assisted  by  Dr.  C.  M.  Bell,  of  this  city,  it  was  easily 
performed  in  the  following  manner:  The  leg  was  raised  from  the  bed, 
the  thigh  flexed  on  the  pelvis.  Dr.  Bell  then  placed  his  thumb,  as  a 
fulcrum,  beneath  the  under  (posterior)  surface  of  the  patella,  and 
pressed  on  the  upper  (anterior)  surface;  at  the  same  time  I  slightly 
flexed,  then  suddenly  extended  and  rotated  the  leg  inwards.  The 
patella  immediately  resumed  its  natural  position."^ 

Dr.  Sternberg,  assistant  surgeon  U.  S.  A.,  has  also  published  a  case 
in  the  Medical  and  Surgical  Reporter,  reduced  readily  when  the  patient 
was  under  the  influence  of  chloroform.  I  am  unable  to  find  the  date 
of  the  record,  but  I  think  it  was  in  1869. 

Dr.  J.  M.  Boyd,  of  Thorntown,  Indiana,  reports  a  case  of  vertical 
dislocation ;  the  patella  resting  upon  its  internal  margin,  in  a  negro 
88  years  old,  and  which  was  caused  by  muscular  "  spasms."  Attempts 
were  immediately  made  by  a  surgeon  to  reduce  it,  but  without  suc- 
cess. Subsequently  Dr.  Boyd  tried  also  and  failed,  but  at  the  end  of 
two  weeks  the  muscular  spasms  returned,  and  before  Dr.  Boyd  could 
reach  the  house  the  bone  had  resumed  its  position  spontaneously.^ 
Malgaigne  has  reported,  also,  a  case  in  the  Gazette  Medicate,  for  1836, 
in  which  reduction  was  accomplished  spontaneously  during  an  attempt 
made  by  the  patient  to  walk.  The  same  writer  refers  to  a  case  re- 
duced under  the  influence  of  chloroform.  Mr.  Flower  {Holmes'  Sur- 
gery) records  a  similar  case. 

In  a  case  of  the  same  kind,  published  originally  in  Rust''s  Magazine, 
and  which  is  copied  at  length  by  Mr.  B.  Cooper  in  his  edition  of  Sir 
Astley's  great  work,  the  reduction  was  found  impossible,  notwith- 
standing the  surgeon  finally  had  the  temerity  to  sever  completely  the 
tendon  of  the  quadriceps  extensor,  and  the  ligamentum  patellte.  Ex- 
tensive suppuration  followed,  under  which  the  poor  fellow  finally  sank 
and  died. 

It  is  scarcely  necessary  to  say  that,  rather  than  expose  the  patient 
to  such  hazards,  it  would  be  better  to  leave  the  bone  unreduced. 

§  4.  Dislocations  of  the  Patella  Upwards. 

Occasionally  the  ligamentum  patellce  has  been  found  so  much  elon- 
gated and  relaxed,  as  to  permit  the  patella  to  glide  upwards  upon  the 
front  of  the  femur.  Heister  and  Ravaton  have  each  seen  an  example 
in  which  a  displacement  from  this  cause  existed  to  the  extent  of  three 
inches.  It  is  much^more  common,  however,  to  meet  with  this  dislo- 
cation as  a  result  of  a  rupture  of  the  ligamentum  patellse,  as  the  fol- 
lowing example  will  illustrate. 

'  Morris,  New  York  Med.  Record,  May,  15,  1869. 

2  Boyd,  Western  Journ.  Med.,  May  1868,  p.  27o,  and  June,  1868,  p.  311. 


DISLOCATIONS    OF    THE    HEAD    OF    THE    TIBIA.  703 

On  the  IStli  of  Dec,  1850,  Dennis  Milliards,  set.  50,  was  admitted 
to  the  surgical  wards  of  the  Buffalo  Hospital  of  the  Sisters  of  Charity. 
While  at  work  on  this  same  day,  he  had  slipped  and  fallen,  with  his 
knee  forcibly  flexed  under  his  body,  I  found  the  ligament  of  the 
patella  torn  asunder,  and  the  patella  drawn  up  two  or  three  inches 
upon  the  front  of  the  thigh.  We  applied  at  once  the  dressings  used 
by  me  for  a  broken  patella,  and  were  able  to  bring  the  bone  down 
completely  to  its  place.  Three  weeks  from  the  time  of  the  receipt  of 
the  injury  the  dressings  were  removed,  and  the  patella  was  found  to 
be  nearly  but  not  quite  in  its  original  place.  From  this  time  we 
commenced  to  move  the  joint :  in  about  ten  days  more  he  left  the 
hospital,  and  I  lost  sight  of  him,  so  that  I  am  unable  to  speak  more 
definitely  of  the  result. 

In  February,  1869,  Dr.  George  H.  Smith  consulted  me  in  relation 
to  a  gentleman  who  had  ruptured  the  ligament  of  the  patella  in  both 
legs,  a  little  more  than  a  year  before,  by  catching  his  heel  in  descend- 
ing from  a  carriage ;  the  ligaments  giving  way  in  the  powerful 
muscular  effort  which  he  made  to  prevent  himself  from  falling. 

Treated  upon  a  single  inclined  plane  in  the  same  manner  that  I 
have  recommended  for  a  fractured  patella,  at  the  end  of  five  weeks  the 
patellee  were  in  place  and  the  ligaments  reunited.  After  walking 
about  one  month  upon  crutches  he  caught  the  heel  of  his  right  foot 
again,  and  again  ruptured  the  ligament  of  the  patella  in  the  same  leg. 
A  similar  plan  of  treatment  failed  to  accomplish  anything,  and  when 
he  consulted  me  the  patella  was  displaced  three  inches  upwards.  He 
could  raise  the  leg  slowly  to  a  position  of  extension  while  sitting,  and 
was  able  to  walk  four  or  five  miles  a  day. 

Gibson  has  recorded  a  similar  case,  in  which  both  patellae  were  dis- 
located upwards  by  a  rupture  of  the  ligaments,  occasioned  by  the 
exercise  of  leaping.  He  recovered  the  use  of  his  limbs  almost  com- 
pletely.' 

(For  examples  of  rupture  of  the  quadriceps  feraoris,  which  some 
writers  have  incorrectly  named  Dislocations  of  the  Patella  Down- 
wards, see  VelpeaiCs  Surgery,  1st  Amer.  ed.,  vol.  i.  p.  422 ;  Neto  York 
Med,  Times,  April  6,  1861,  p.  226,  and  two  cases  reported  by  myself 
in  the  same  vol.  of  the  Med.  Times.) 


CHAPTER   XVIII. 

DISLOCATIONS  OF  THE  HEAD  OF  THE  TIBIA. 

Syn. — "  Tibia  upon  tlie  femur  ;"  "  dislocations  of  the  leg." 

In  consequence  of  the  great  size  and  irregularity  of  the  articular 
surfaces  between  the  tibia  and  femur,  tos-ether  with  the  remarkable 
number  and  strength  of  the  ligaments  which  bind  the  two  bones 

'  Gibson,  Surgery,  vol.  i.  p.  395,  Ctli  ed. 


704 


DISLOCATIONS    OF    THE    HEAD    OF    THE    TIBIA. 


together,  dislocations  at  this  joint  are  exceedingly  rare.  They  are 
known  to  take  place  however,  in  four  principal  directions,  namely, 
backwards,  forwards,  inwards,  and  outwards.  A  dislocation  may  also 
occur  in  either  of  the  diagonals  between  these  points,  that  is,  antero- 
laterally  or  postero-laterally.  They  may  be  either  complete  or  incom- 
plete, Yelpeau  has  found  upon  record  thirteen  examples  of  complete 
dislocations  forwards  and  eight  backwards,  but  not  one  of  a  complete 
lateral  luxation.  Velpeau  thought,  also,  that  the  antero-posterior 
luxations  were  always  complete,  but  Malgaigne  has  shown  that  this 
opinion  is  erroneous. 

Simple  flexion  and  extension,  however  extreme,  are  generally  insuf- 
ficient to  produce  either  of  these  dislocations.  They  may  be  produced 
by  a  violent  blow  upon  the  lower  end  of  the  femur  or  upon  the  upper 
end  of  the  tibia,  or  by  twisting  the  tibia  upon  the  femur,  as  when  the 
foot  is  made  fast  in  a  hole,  and  the  body  swings  around  upon  the  knee. 

§  1.  Dislocations  op  the  Head  of  the  Tibia  Backwards, 

Symptoms. — The  head  of  the  tibia  is  felt  in  the  popliteal  space ;  and, 
if  the  dislocation  is  complete,  the  pressure  upon  the  popliteal  nerve 
becomes  excessively  painful, 

A  marked  depression  exists  in  front,  immediately  below  the  patella, 
and  especially  upon  the  sides  of  the  ligamentum  patellae ;  the  con- 
dyles of  the  femur  project  strongly  in  front ;  the  leg  may  be  not  at  all 
or  only  slightly  shortened,  or  the  shortening  may  amount  to  one  inch 
or  more,  and  usually  it  is  in  a  position  of  extreme  extension,  or  thrown 
forwards  from  the  line  of  the  axis  of  the  femur;  but  its  position  has 
been  found  to  vary  greatly  in  different  cases,  the  limb  being  some- 
times very  much  flexed,  and  in  others  very  slightly  flexed,  or  perfectly 
straight. 

Pathological  Anatomy. — The  posterior  ligament  of  the  joint  is  torn  ; 
the  muscles  of  the  ham  are  put  upon  the  stretch  ;  the  popliteal  nerves 
and  vessels  compressed  ;  and  the  head  of  the 
tibia  either  rests  partly  upon  the  posterior  half 
of  the  lower  articulating  surface  of  the  femur,  or 
it  passes  up  and  rests  only  against  its  posterior 
articulating  surface,  which  in  this  direction  ex- 
tends an  inch  or  more  upwards.  If  the  disloca- 
tion is  complete,  the  crucial  ligaments  are  also 
torn,  and  all  the  parts  about  the  joint  suffer  ex- 
tensive injury  from  stretching,  laceration,  or 
compression. 

Prog7iosis. — Malgaigne  has  seen  three  ex- 
amples of  incomplete  backward  luxations  which 
were  not  reduced,  and  neither  of  the  persons 
was  very  greatly  maimed  in  consequence.  One 
walked  with  crutches  after  three  or  four  days, 
and  with  a  cane  after  about  five  weeks.  An- 
other did  not  leave  his  bed  under  one  month, 
and  it  was  nearly  one  year  before  he  could  lay 
aside  his  crutches  ;  but  both  of  them  were  finally 


Fiff.  308. 


Dislocation  of  the  head  of 
the  tibia  backwards. 


DISLOCATIOXS    OF    HEAD    OF    TIBIA    BACKWARDS.       705 

able  to  walk  at  least  twelve  leagues  per  day.  Malgaigne  informs  us, 
however,  that  in  a  similar  case  seen  by  Lassus,  the  patient  was  confined 
to  his  bed  two  years,  although  he  finally  recovered  a  tolerable  use  of 
his  limb. 

If  the  reduction  is  promptly  effected,  the  limb  kept  perfectly  quiet 
a  sufiicient  length  of  time,  and  in  other  respects  properly  managed, 
not  much  inflammation  need  generally  be  anticipated,  and  the  limb 
may  suffer  in  the  end  very  little  if  any  maiming. 

Treatment. — It  will  be  proper,  at  first,  to  attempt  the  reduction  by 
simple  manipulation,  as  this  is  often  found  to  succeed  when  the  dis- 
location is  recent  and  incomplete,  and  especially  when  the  system  is 
greatly  depressed  by  the  shock  of  the  injury.  If  the  dislocation  is 
complete,  however,  we  can  hardly  anticipate  success  without  the  ap- 
plication of  some  extending  force. 

In  the  employment  of  manipulation  we  ought  to  be  governed  at 
first  by  the  same  rule  which  we  have  found  so  generally  applicable  in 
dislocations  of  the  femur,  namely,  to  carry  the  limb  in  those  directions 
in  which  it  will  move  easily,  or  without  much  force.  If  this  fails,  we 
may  at  once  resort  to  forced  flexion  alternating  with  extension,  rotat- 
ing or  rocking  the  limb  also  occasionally  from  one  side  to  the  other, 
while  at  the  same  moment  strong  pressure  is  made  upon  the  project- 
ing bones  at  the  knee-joint  in  opposite  directions  or  in  the  direction 
of  the  articulation. 

Finally,  it  may  be  necessary  to  resort  to  extension,  made  by  means 
of  a  lacq,  or  by  the  hands  of  strong  assistants,  above  the  ankle,  always 
at  first  in  the  direction  of  the  axis  of  the  tibia  ;  the  counter-extending 
band  being  applied  to  the  perineum  if  the  leg  is  straight,  but  to  the 
lower  and  back  part  of  the  thigh  if  the  leg  is  flexed. 

A  very  convenient  mode  of  making  extension,  where  we  wish  to 
apply  more  than  usual  force,  is  to  lay  the  whole  limb  over  a  firm 
double-inclined  plane,  or  fracture  splint,  securing  the  thigh  to  the 
thigh-piece  with  a  roller,  and  making  the  extension  with  the  screw 
attached  to  the  foot-board.  This  method,  however,  while  it  enables' 
us  to  use  great  force  in  the  extension,  prevents  the  surgeon  from  em- 
ploying, at  the  same  time,  those  flexions,  extensions,  and  other  ma- 
nipulations, upon  which  success  so  often  depends. 

Dr.  James  Carmichael  has  reported  a  case  in  which  reduction  was 
effected  easily  by  flexion,  when  traction  had  failed.^ 

Mr.  Rose  has  related,  in  the  Provincial  Medical  Journal  oi  June  11th, 
1842,  a  characteristic  example  of  this  accident,  except  that  the  patella 
had  also  suffered  a  lateral  displacement,  presenting  the  usual  favorable 
termination. 

A  woman  was  standing  upon  a  low  ladder,  when  a  carriage  driven 
furiously  came  in  contact  with  it,  and  precipitated  her  to  the  ground. 
Mr.  Rose,  who  saw  her  almost  immediately,  found  the  tibia  completely 
dislocated  at  the  knee,  the  head  being  driven  behind  the  condyles  of 
the  femur  into  the  ham,  with  the  patella  thrown  to  the  outside  of  the 
external  condyle,  and  the  leg  in  a  state  of  fixed  extension.     Immedi- 

1  Xew  York  Med.  Gazette,  Aug.  22,  18G8;  from  the  Lancet. 


706 


DISLOCATIONS    OF    THE    HEAD    OF    THE    TIBIA. 


ately,  and  witbout  difficulty,  the  bones  were  restored  by  applying  one 
hand  to  the  patella,  the  other  to  the  back  of  the  upper  portion  of  the 
tibia,  and  simultaneously  pulling  and  pushing  those  bones  toward 
their  natural  positions.  The  patient  was  then  removed  to  a  bed,  and 
by  the  diligent  use  of  antiphlogistic  remedies  inflammation  was  kept 
in  check,  and  the  case  reached  a  favorable  termination  without  one 
untoward  symptom.  After  the  lapse  of  only  a  few  weeks,  she  had 
completely  recovered  the  use  of  the  knee-joint.^ 

Dr.  Walsham  communicated  a  case  to  Sir  Astley  Cooper,  in  which 
the  dislocation  was  not  only  complete,  but  the  tendon  of  the  quadri- 
ceps extensor  was  ruptured.  The  leg  was  bent  forwards.  The  reduc- 
tion was  accomplished  very  easily  by  extension  made  with  the  hands 
by  four  men,  in  the  line  of  the  axis  of  the  limb.  In  about  one  month 
this  man  began  to  walk  with  crutches,  but  he  was  not  perfectly  re- 
covered until  after  five  months;  at  which  time  the  crutches  were 
finally  laid  aside.^ 


Fig.  309. 


§  2.  Dislocations  of  the  Head  op  the  Tibia  Forwards. 

The  signs  of  this  accident  are  the  reverse  of  those  which  belong  to 
dislocations  backwards.  The  patella,  tibia,  and  fibula  are  prominent 
in  front,  while  the  condyles  of  the  femur  may  be  felt  behind,  pressing 
strongly  upon  the  muscles,  nerves,  and  bloodvessels  which  occupy  the 
popliteal  space.     In  case  the  dislocation  is  complete,  a  shortening  may 

exist  to  the  extent  of  one  or  even  three 
inches.  Dr.  O'Beirne,  of  Dublin,  has  men- 
tioned a  case  to  Mr.  B.  Cooper,  in  which 
the  shortening  was  three  inches  and  a  half, 
and  Mr.  Mayo  has  seen  one  example  in 
which  the  dislocated  limb  was  "fully  four 
inches"  shorter  than  the  other.^ 

In  consequence  of  the  pressure  upon 
the  popliteal  artery,  the  pulsations  in  the 
branches  below  are  frequently  interrupted, 
and  in  one  instance  this  pressure  was  suffi- 
cient to  produce  finally  a  dry  gangrene. 

Dr.  Gorde  relates  a  case  in  the  Bulletin 
de  Therapeutique,  occurring  in  a  woman 
nearly  sixty  years  old.  This  woman  was 
returning  home  at  night  with  a  heavy 
burden,  and  in  a  state  of  intoxication, 
when  she  stepped  into  a  ditch  as  deep  as 
up  to  the  middle  of  her  thighs.  The  body 
was  thrown  forwards  by  the  fall,  while  the 
feet  stuck  at  the  bottom  of  the  ditch ;  the  whole  force  of  the  impulse 
being  sustained  by  the  thighs.  The  lower  end  of  the  femur  was 
found  driven  downwards  and  backwards,  and  lodged  under  the  mus- 

'  Rose,  Amer.  Journ.  Med.  Sci.,  vol.  xxxi.  p.  216. 

2  Walsham,  Sir  A.  Cooper  on  Disloc,  &c.,  3d  Lond.  ed.,  p.  188. 

"  B.  Cooper's  ed.  of  Sir  Astley  Cooper  on  Disloc,  &c.,  pp.  314-315. 


Incomplete  dislocation  of  the  head 
of  the  tibia  forwards. 


DISLOCATIONS    OF    HEAD    OF    TIBIA    FOEWARDS.         707 

cles  of  the  calf  of  the  leg ;  the  limb  being  shortened  three  inches.  Ee- 
duction  was  promptly  effected,  and  without  inflicting  any  pain  of 
which  the  patient  complained.     In  six  weeks  the  patient  was  cured.^ 

Mr.  Toogood  has  reported  also,  in  the  Provincial  Medical  Journal  o^ 
June  18th,  1842,  an  example  of  complete  dislocation  in  this  direction, 
in  which  the  appearance  was  so  dreadful,  that  Mr.  Toogood  at  first 
despaired  of  being  able  to  reduce  it ;  but  by  directing  two  men  to 
make  counter-extension  while  he  made  extension,  the  reduction  was 
immediately  effected.  At  the  end  of  one  month  the  patient  was  able 
to  leave  his  bed  ;  and  sixteen  years  after.  Dr.  Toogood  saw  him  walk- 
ing "with  very  little  lameness."^  Parker,  of  Liverpool,  has  reported 
another  example  in  the  London  and  Edinburgh  Moyithly  Journal  for 
December,  1842,  which  was  occasioned  by  the  fall  of  a  heavy  spar 
upon  a  man's  back,  and  the  consequent  violent  bending  of  the  knee 
under  his  body.  In  this  case  the  limb  was  slightly  flexed,  and  the 
patella  was  loose  and  floating.  The  reduction  was  effected  without 
much  difficulty  by  extension  and  counter-extension  made  by  two  men, 
while  the  operator,  placing  his  knee  in  the  ham  of  the  patient,  attempted 
to  bring  the  leg  to  a  right  angle  with  the  thigh.^ 

B.  Cooper,  Malgaigne,  Little,"*  and  others,  have  recorded  examples 
of  this  accident. 

March  9th,  1865,  Hiram  Wescott,  of  Sandy  Cove,  Nova  Scotia,  set. 
45,  was  caught  by  his  sled,  drawn  by  horses,  in  sucb  a  way  that  a 
beam  pressed  against  the  front  and  lower  end  of  the  femur  while  the 
heel  was  caught  and  arrested  by  a  stump.  The  foot  was  thrown  for- 
wards and  the  upper  end  of  the  tibia  completely  dislocated  in  the 
same  direction.  It  was  at  once  reduced  by  a  person  who  was  present, 
but  on  attempting  to  use  the  leg  in  walking  it  was  reluxated  immedi- 
ately. Mr,  J.  H.  Harris,  medical  student,  found  the  limb  soon  after 
completely  luxated,  with  the  leg  thrown  forwards  in  the  position  of 
dorsal  flexion  about  40°.  The  tendons  of  the  hamstring  muscles  were 
not  ruptured,  but  had  slid  forwards  past  the  condyles  of  the  femur. 
There  was  no  external  wound.  Eeduction  was  easily  accomplished 
by  simple  extension.  Pasteboard  splints  were  then  applied.  On  the 
third  day  the  knee  was  considerably  swollen,  and  some  ecchymosis 
existed  about  the  popliteal  region.  On  the  fifth  day  these  symptoms 
had  much  increased.  Mr.  Harris  then  applied  extension  to  the  foot, 
with  the  aid  of  adhesive  plaster,  pulley  and  weights,  and  by  elevating 
the  foot  of  the  bed.  The  amount  of  extension  employed  was  9  lbs. 
This  gave  immediate  relief  to  the  pain,  and  was  continued  until  the 
inflammation  subsided.  His  recovery  was  steady,  and  in  four  months 
he  walked  with  crutches  or  a  cane. 

In  1«64  a  similar  dislocation  was  presented  at  the  Brooklyn  City 
Hospital,  in  which  reduction  having  been  practised,  the  patient  died. 
The  case  is  reported  very  fully  by  Dr.  Le  Eoy  M.  Yale.^ 

'  Gorde,  Arner.  Journ.  Med.  Sci.,  vol.  xvi.  p.  225,  Maj-,  1835. 

2  Toogood,  Arner.  Journ.  Med.  Sci.,  vol.  xxxi.  p.  465.  ^  E.  Parker,  Ibid. 

4  Little,  New  York  Med.  Times,  Aug.  17,  1861. 

5  Yale,  N.  Y.  Journ.  Med.,  vol.  ii.  p.  124,  Nov.  1865. 


708 


DISLOCATIONS    OF    THE    HEAD    OF    THE    TIBIA. 


Dr.  White,  of  Buftalo,  politely  invited  me  to  see  with  him  a  lad,  get. 
10,  whose  tibia  had  been  partially  dislocated  forwards  eight  weeks 
before,  by  a  boy's  having  hit  the  top  of  his  knee  with  his  head,  while 
they  were  at  play.  His  father,  who  is  himself  a  physician,  residing 
near  town,  reduced  the  limb  very  easily,  by  extension  made  with  his 
own  hands,  and  by  pressing  upon  the  projecting  bones.  Violent  in- 
flammation ensued,  but  at  the  time  when  I  saw  him,  the  knee  was 
free  from  soreness  or  swelling,  and  the  motions  of  the  joint  were  nearly 
restored. 

D.  Charles  S.  Downes,  of  Mclndoe's  Falls,  Vt.,  has  sent  me  the  fol- 
lowing account  of  a  case  which  occurred  in  his  own  practice.  Oct. 
1861,  Mrs.  H.,  a  robust  young  married  woman,  aged  about  20  years, 
was  driving  a  young  horse  and  holding  her  infant  in  her  arras,  when 
the  horse  ran  and  she  was  thrown  out.  One  of  her  legs  being  caught 
in  the  wheel,  she  was  carried  over  three  or  four  times  in  its  revolutions 
before  she  became  disengaged,  holding  meanwhile  upon  her  infant  with 
such  firmness  that  it  suffered  no  harm. 

A  few  hours  later  Dr.  Downes  and  Dr.  Burton  found  a  complete 
dislocation  of  the  tibia  and  fibula  forwards,  and  the  lower  end  of  the 
femur  could  be  felt  under  the  muscles  of  the  calf  of  the  leg.  The 
limb  was  shortened  four  inches  and  a  half.  The  patella  lay  loosely 
in  front  of  the  femur,  with  its  lower  margin  tilted  forwards. 

The  patient  was  laid  upon  a  bed,  and  a  perineal  band  made  fast  to 
one  of  the  posts,  while  a  lacq  was  placed  upon  the  foot  and  attached 
to  a  rope  folded  upon  itself  and  forming  a  pulley  or  "Spanish  windlass," 
such  as  is  described  at  p.  650.  In  this  way  the  reduction  was  speedily 
and  easily  accomplished.  Hot  fomentations  were  subsequently  applied 
for  several  days,  the  limb  being  kept  perfectly  at  rest.  In  about  three 
months  she  was  able  to  do  her  own  housework,  and  in  a  short  time 
after  all  traces  of  her  accident  had  disappeared. 


§  3.  Dislocations  of  the  Head  of  the  Tibia  Outwards. 

Occasionally,  owing  to  a  violent  wrench  of  the  knee-joint,  the  lat- 
eral ligaments  upon  one  side  or  the  other  are  ruptured,  and  conse- 
quently the  joint  surfaces  separate  somewhat  from  each  other ;  or  when 
the  limb  is  moved,  the  head  of  the  tibia  may  slide  a  little  forwards  or 
backwards,  or  to  either  side.  These  are  not  properly  examples  of 
subluxation;  nor  should  we  consider  as  belonging  to  this  class  the 
accident  originally  described  by  Mr.  Hey  as  an  "  internal  derange- 
ment of  the  knee-joint,"  but  which  also  by  some  writers  has  been 
termed  a  "  subluxation  of  the  knee."  Of  this  latter  accident  I  will 
take  occasion  hereafter  to  speak  a  little  more  particularly. 

In  subluxation,  properly  so  called,  if  the  direction  of  the  disloca- 
tion is  outwards,  the  outer  condyle  of  the  femur  rests  upon  the  inner 
articulating  surface  of  the  tibia,  and  if  the  direction  of  the  dislocation 
is  inwards,  the  inner  condyle  of  the  femur  rests  upon  the  outer  articu- 
lating surface  of  the  tibia. 

The  signs  which  characterize  this  accident  are  such  as  cannot  easily 
be  mistaken.     The  limb  is  not  shortened,  nor  is  there  anything  espe- 


DISLOCATIONS    OF    HEAD    OF    TIBIA    OUTWARDS. 


•09 


Fi!?.  310. 


cially  diagnostic  in  its  position,  since  it  lias  been  found  to  be  some- 
times flexed,  and  at  other  times  straight ;  but  the  strong  lateral 
projections  made  by  the  inner  condyle  of  the  femur  on  the  one  hand, 
and  by  the  heads  of  the  tibia  and  fibula  on  the  other,  cannot  fail  to 
inform  us  as  to  the  true  nature  of  the  accident. 

The  treatment  will  not  differ  essentially  from  that  which  has 
already  been  recommended  in  dislocation  of  the  tibia  backwards  or 
forwards.  If  any  other  expedients  can  prove  use- 
ful, they  must  be  left  to  the  judgment  of  the  sur- 
geon whenever  the  exigencies  of  the  case  shall 
demand  them. 

I  have  already  mentioned  the  case  of  N.  Smith, 
who,  in  consequence  of  a  fall  from  a  window,  had 
a  dislocation  of  the  right  femur,  tibia,  and  patella. 
The  tibia  was  subluxated  outwards,  and  the  leg 
was  partially  flexed  upon  the  thigh,  with  the  toes 
everted.  By  moderate  extension,  made  with  my 
own  hands,  united  with  alternate  flexion  and  ex- 
tension, the  bone  was  easily  and  promptly  restored 
to  its  place.  Having  reduced  the  femur  also,  the 
limb  was  laid  over  a  gently  inclined  plane  made 
of  pillows ;  and  cloths  moistened  with  cool  water 
were  kept  constantly  applied  to  the  knee  for  many 
days.  Very  little  swelling  followed  the  accident, 
and  his  recovery  was  rapid  and  complete. 

A  man  was  received  into  the  North  London 
Hospital,  with  a  partial  dislocation  of  the  tibia 
outwards,  and  although  the  knee  was  much  swol- 
len, the  nature  of  the  injury  was  easily  determined.     The  knee  was 
immovable,  and  the  toes  turned  outwards.     Mr.  Hallam,  the  house 
surgeon,  reduced  it  by  extension  and  counter-extension  made  by  his 
own  hands.^ 

Mr.  Pitt  records  a  similar  case  in  a  young  lady,  produced  by  a  fall 
down  a  flight  of  stairs.  It  was  reduced  easily  by  extension  and. 
counter-extension.  Inflammation  followed,  but  it  was  finally  con- 
trolled, and  she  regained  the  use  of  her  limbs.^ 

In  one  case  of  subluxation,  mentioned  by  Sir  Astley  Cooper,  and 
in  a  second  recorded  by  Bransby  Cooper,  the  recovery  of  the  func- 
tions of  the  joint  did  not  seem'  to  have  been  so  rapid ;  the  joint 
remaining  unstable  and  tender  for  a  long  time  afterwards.^ 


Subluxatiou  of  the  head 
of  the  tibia  outwards. 


§  4.  Dislocations  or  the  Head  of  the  Tibia  Inwards. 

There  is  nothing  peculiar  in  either  the  signs,  condition,  or  treatment 
of  this  accident,  as  distinguished  from  a  dislocation  outwards,  to  de- 
mand of  us  a  special  consideration. 

Sir  Astley  Cooper  has  mentioned  two  cases  of  subluxation  inwards, 

'  Hallam,  Amer.  Joum.  Med.  Sci.,  vol.  xix.  p.  251. 

2  Pitt,  Ibid.,  vol.  xxxi.  p.  465. 

3  B.  Cooper's  ed.  of  Sir  Astley,  op.  cit.,  pp.  111-13. 


710 


DISLOCATIONS    OF    THE    HEAD    OF    THE    TIBIA, 


and  Mr.  B.  Cooper  has  added  to  these  a  third.  Sir  Astley  remarks 
that  in  the  first  accident,  the  only  one  indeed  which  he  had  himself 
ever  seen,  he  was  struck  with  three  circumstances:  first,  the  great 
deformity  of  the  knee  from  the  projection  of  the  tibia ;  second,  the 
ease  with  which  the  bone  was  reduced  by  direct  extension  ;  and  third, 
by  the  little  inflammation  which  followed.  The  second  case  of  which 
Sir  Astley  speaks  was  communicated  to  him  by  a  Mr.  Eichards.  In 
this  case  the  fibula  was  also  broken,  and  the  reduction  was  accom- 
plished only  after  extension  had  been  made  by 
several  persons  for  half  an  hour.  The  limb  became 
excessively  swollen,  and  remained  so  for  many 
weeks.  Eighteen  months  after  the  accident  the 
knee  continued  somewhat  stiff,  and  there  was  an 
unnatural  lateral  motion  in  the  joint,  from  the  in- 
jury which  the  ligaments  had  sustained.  The  pa- 
tient referred  to  by  Bransby  Cooper  had  met  with 
the  accident  by  a  fall  upon  the  foot,  with  his  leg 
bent  under  him  ;  and  a  fellow- workman  had  re- 
duced the  bone  by  extension  and  pressure.  Mr. 
Cooper  thinks  that  not  only  the  internal  lateral 
ligament  was  torn,  but  also  some  fibres  of  the  vas- 
tus externus  and  the  crucial  ligaments.  Violent 
inflammation  ensued,  which  did  not  permit  him  to 
leave  the  hospital  until  after  about  two  weeks.' 
Fergusson  has  seen  two  examples  of  unreduced 
subluxation  inwards,  in  both  of  which  the  patients 
had  regained  useful  limbs.* 

Malgaigne  mentions  that  Boyer,  Costallat,  and 
Key  had  each  seen  one  similar  example;  and  he  also  enumerates  two 
additional  cases  of  complete  luxation  attended  with  a  protrusion  of 
the  bone  through  an  external  wound;  in  both  of  which  the  reduction 
was  easily  effected  and  the  patients  recovered.^ 

§  5.  Dislocations  of  the  Head  of  the  Tibia  Backwards  and  Outwards. 

In  June,  1853,  Henry  J.,  of  Dansville,  N.  Y.,  set.  24,  was  thrown  by 
an  enraged  bull,  and  his  left  leg  being  caught  under  the  knee  by  the 
horns,  was  twisted  violently.  Dr.  Prior,  of  Dansville,  and  Batton,  of 
Burns,  were  called,  and  found  the  left  knee  completely  dislocated; 
the  tibia  being  displaced  backwards  beyond  the  condyles  of  the  femur, 
and  also  a  little  outwards.  The  foot  and  leg  were  inclined  outwards. 
With  the  assistance  of  four  men,  extension  and  counter-extension  were 
made  in  the  line  of  the  axis  of  the  limb,  and  the  reduction  was  easily 
accomplished.  Pasteboard  splints,  bandages,  &;c.,  were  applied  to 
maintain  the  bones  in  place;  but  the  swelling  came  on  rapidly,  and 
in  the  evening  these  dressings  were  removed.  The  limb  was  now  laid 
over  a  double-inclined  plane  carefully  padded,  in  order  to  press  the 

'  B.  Cooper's  ed.  of  Sir  Astley,  op.  cit.,  pp.  111-13. 

2  Fergusson,  op.  cit.,  p.  284. 

3  Malgaigne,  op.  cit.,  torn.  ii.  p.  950. 


Subluxation  of  the  head 
of  the  tibia  inwards. 


INTEKXAL    DERANGEMENT    OF    THE    KNEE-JOINT.      711 

upper  end  of  the  tibia  forwards,  as  it  manifested  a  constant  inclination 
to  become  displaced  backwards.  This  apparatus  was  employed  six 
weeks,  with  the  exception  of  two  or  three  days,  during  which  the 
limb  was  laid  upon  pillows,  but  as  the  pillows  did  not  sufficiently 
support  the  back  of  the  tibia,  the  double-inclined  plane  was  resumed. 
After  the  removal  of  the  plane,  during  seven  weeks  longer,  an  angular 
splint  was  kept  closely  applied  to  the  back  of  the  limb. 

Seven  months  after  the  accident,  on  the  23d  of  January,  1854,  Dr. 
Eobinson,  of  Hornellsville,  brought  the  gentleman  to  me.  I  found  the 
bones  displaced  backwards  about  three-quarters  of  an  inch,  and  half 
an  inch  outwards,  or  to  the  fibular  side.  This  was  the  position  of  the 
bones  when  he  was  sitting  with  his  leg  bent  at  a  right  angle  with  the 
thigh,  but  when  he  stood  erect  and  bore  some  weight  upon  the  foot, 
the  outward  displacement  ceased,  and  the  backward  displacement  only 
remained.  It  was  very  easy,  however,  in  whatever  position  the  leg 
might  be,  to  push  the  bones  forwards  by  the  hands  until  nearly  all 
deformity  had  disappeared.  He  could  flex  the  leg  to  a  right  angle 
with  the  thigh,  and  straighten  it  completely,  but  he  could  not  lift  the 
foot  and  leg  from  the  floor  while  sitting  with  his  limb  extended  in 
front  of  him.  He  was  unable  to  bear  sufficient  weight  upop  his  foot 
to  use  it  at  all  in  progression,  on  account  of  the  inability  to  fix  and 
steady  the  limb,  but  not  on  account  of  any  pain  or  soreness  which  it 
occasioned. 

It  was  very  plain  that  the  surgeons  were  not  in  fault  for  this  un- 
fortunate condition ;  indeed,  they  seem  to  have  exercised  throughout 
great  ingenuity  and  skill  in  its  management. 

I  directed  the  young  man  to  Mr.  John  C.  Seiffert,  of  Buffalo,  a  very 
ingenious  instrument-maker,  who  has  since  succeeded,  I  learn,  in 
adapting  to  his  knee  a  mechanical  contrivance  which  enables  him  to 
walk  quite  well. 

Thomas  Wells,  of  Columbia,  South  Carolina,  has  described  a  similar 
accident,  the  tibia  being  dislocated  outwards  and  backwards,  which 
terminated  fatally  on  the  fourth  day  in  consequence  mainly  of  ex- 
posure, intemperance,  and  neglect  to  apply  for  surgical  aid.  The 
bones  were  never  reduced,  and  the  autopsy  dislosed  also  a  fracture 
of  the  internal  condyle  of  the  femur.^ 

§  6.  Internal  Derangement  of  the  Knee-Joint. 

Syn. — "Slipping  of  the  semilunar  fibro-cartilages;"  Hey.  "Partial  dislocation 
of  the  thigh-bone  from  the  semilunar  cartilages;"  Sir  Astley  Cooper.  "Subluxa- 
tion of  the  semilunar  cartilages;"  Malgaigne.  "Subluxation  of  the  knee;"  Erich- 
sen.  To  these  we  think  it  proper  to  add,  as  giving  rise  to  the  same  class  of  symp- 
toms, "Floating  cartilages  in  the  knee-joint." 

We  have  already  expressed  our  opinion  that  this  accident  is  in  no 
proper  sense  a  subluxation  of  the  knee;  and  we  should  not,  therefore, 
think  it  worth  while  to  make  any  farther  allusion  to  it,  were  it  not  neces- 
sary in  order  to  enable  the  student  of  surgery  to  distinguish  between 
the  phenomena  which  belong  to  it  and  those  which  belong  strictly  to 
subluxation  of  this  joint. 

'  "Wells,  Amer.  Journ.  Med.  Sci.,  vol.  x.  p.  35,  May,  1832. 


712  DISLOCATIONS    OF    THE    HEAD    OF    THE    TIBIA. 

Symptoms. — The  patient  is  suddenly  thrown  to  the  ground  while 
walking,  as  if  by  an  instantaneous  loss  of  power  in  the  affected  limb, 
this  loss  of  control  over  the  limb  being  accompanied  usually  with 
sharp  pain,  referred  to  the  region  of  the  knee-joint;  or  he  trips  his 
toe  against  something  in  his  path,  and  the  toes  becoming  everted,  the 
leg  suddenly  gives  way  under  him ;  in  some  cases  it  has  happened 
when  the  patient  was  turning  in  bed,  the  weight  of  the  bedclothes 
hanoing  upon  the  toes  so  as  to  occasion  a  strain  and  rotation  outwards 
at  the  knee-joint,  or  it  follows  upon  a  subluxation  of  the  joint,  as  in 
one  example  which  I  shall  presently  relate. 

If  the  patient  is  walking  when  the  accident  takes  place,  and  he  falls 
to  tbe  ground,  he  finds  himself  unable  to  move  the  limb,  or  to  stand 
upon  it;  but  by  manipulation,  the  difficulty  is,  in  most  cases,  as  easily 
overcome  as  it  occurred,  when  immediately  the  motions  of  the  joint 
become  free,  and  he  walks  oft'  as  if  nothing  had  happened. 

"When  the  accident  has  once  taken  place,  it  is  afterwards  exceed- 
ingly liable  to  occur  from  very  slight  causes,  and  eventually  the  knee- 
joint  becomes  tender  and  tlie  capsule  fills  with  synovia,  indicating  the 
existence  of  subacute  synovitis. 

A  single  example  will  illustrate  the  usual  history  of  these  cases. 

A  young  man,  from  Colesville,  N.  Y.,  £et.  23,  consulted  me  on  the 
27th  of  Oct.  1858,  in  relation  to  the  condition  of  his  knee-joint.  He 
stated  that  on  the  13th  of  Aug.  1858,  while  standing  with  the  whole 
weight  of  his  body  resting  upon  the  left  leg,  a  mate  struck  him  on  the 
inside  of  the  lower  end  of  the  left  femur.  The  blow  was  made  with 
the  palm  of  the  hand,  but  with  sufficient  force  to  throw  him  down.  It 
was  immediately  noticed  that  the  tibia  was  partially  dislocated  inwards 
at  the  knee-joint.  The  whole  lower  part  of  the  limb  was  inclined 
outwards.  A  person  present  in  the  room  seized  upon  the  foot  and 
by  extension  easily  brought  it  back  to  place ;  the  bone  resuming  its 
position  with  an  audible  snap.  After  this  he  continued  to  walk  about 
until  night.  Two  days  after,  the  knee  had  become  so  much  inflamed 
that  he  was  obliged  to  take  to  his  bed,  on  which  he  was  confined  three 
weeks.  Gradually  the  swelling  subsided,  and  in  about  five  weeks 
after  the  accident  he  began  to  walk  on  crutches.  On  the  23d  of  Sept., 
he  was  walking  in  the  store  without  crutches,  when  he  suddenly  felt 
a  sensation  of  slipping  in  the  joint,  and  he  fell  to  the  floor  as  if  he 
had  been  tripped  up.  At  the  time  when  he  called  upon  me,  this  had 
happened  many  times,  but  had  never  been  attended  with  pain.  The 
joint  was  filled  with  synovia,  and  tender,  yet  I  could  distinctly  feel  a 
hard  body  just  to  the  inside  of  the  liganientum  patellae,  and  which 
moved  freely  under  the  finger. 

Pathological  Anatomy. — The  same  class  of  symptoms,  with  only 
very  slight  modification,  belongs  probably  to  several  varieties  of  "in- 
ternal derangement  of  the  knee-joint;"  and  first  it  will  be  remembered 
that  the  semilunar  cartilages  upon  which  the  margins  of  the  condyles 
of  the  femur  rest,  are  attached  to  the  tibia  by  several  ligaments;  but 
when,  from  relaxation  or  a  violent  strain,  any  one  of  these  ligaments 
becomes  elongated  or  gives  way,  the  portion  of  cartilage  which  it 


DISLOCATIONS    OF    LOWER    END    OF    THE    TIBIA.         713 

restrains  is  permitted  to  become  partially  displaced,  and  by  interposing 
its  thick  margin  between  the  deeper  articulating  surfaces  the  bones  are 
separated  and  the  muscles  lose  their  control  over  the  joint ;  second, 
these  ligaments  may  not  only  yield,  but  a  fragment  of  one  of  the  car- 
tilages may  become  actually  broken  off  from  the  main  portion  ;  third, 
the  femur  may  perhaps  escape  behind  some  portion  of  an  interarticular 
cartilage,  and  thus,  instead  of  the  cartilage  placing  itself  between  the 
joint  surfaces,  the  femur  itself  may  have  thrust  it  into  this  position ; 
fourth,  a  cartilage  or  some  portion  of  a  cartilage  may  become  hyper- 
trophied,  and  thus  give  rise  to  the  symptoms  described  ;  fifth,  in  other 
cases  still,  a  bony,  cartilaginous,  fibrinous,  or  calcareous  growth  or 
concretion  forming  within  the  joint,  and,  if  originally  attached,  becom- 
ing separated  from  the  capsule,  may  move  about  more  or  less  freely, 
and  give  rise  to  the  same  class  of  symptoms  which  we  have  described. 

This  last  variety  has  generally  been  described  under  the  name  of 
"floating  cartilages;"  but  since  these  bodies  are  not  always  cartilagi- 
nous, and  especially  since  they  do  not  always  by  any  means  move  so 
freely  as  to  be  properly  designated  as  "  floating,"  the  term  is  less 
appropriate  than  that  originally  given  by  Hey,  and  which  we  have 
chosen  to  adopt. 

Treatment. — For  the  purpose  of  obtaining  immediate  relief,  it  is  gen- 
erally sufficient  to  flex  the  leg  completely  and  then  suddenly  extend 
it,  or  to  combine  this  motion  with  a  slight  twisting  or  rocking  of  the 
knee-joint.  Sometimes  this  experiment  has  to  be  repeated  several 
times  before  it  is  completely  successful,  and  in  a  few  instances  it  has 
failed  altogether.  I  think  I  must  have  met  with  ten  or  twelve  ex- 
amples in  the  course  of  my  practice,  and  in  no  instance  has  the  sudden 
flexion  and  extension  of  the  limb  failed  to  overcome  the  difficulty. 

As  to  the  question  of  subsequent  treatment,  especially  as  to  whether 
it  is  proper  to  attempt  their  extirpation  when  they  are  found  to  be 
loose,  or  to  make  any  other  surgical  interference,  I  prefer  to  leave  its 
consideration  to  those  general  treatises  upon  surgery  where  it  more 
properly  belongs. 


CHAPTER    XIX. 

DISLOCATIONS  OF  THE  LOWER  END  OF  THE  TIBIA. 

Syn. — "  Tibio-tarsal  luxations  ;"  Malgaigne.  "  Dislocations  of  the  ankle-joint  ;" 
Chelius  and  others. 

The  tibia  may  be  dislocated  at  its  lower  end  in  four  directions ; 
namely,  inwards,  outwards,  forwards,  and  backwards.  Most  of  these 
dislocations  complicate  themselves  with  fractures  of  the  fibula  or  of 
the  tibia,  or  with  fractures  of  both  bones. 

Dupuytren,  Malgaigne,  and  a  few  other  surgeons  have  reported  ex- 
amples also  of  dislocations  forwards  and  inwards. 

Boyer,  with  a  majority  of  the  French  writers,  and  several  English 
46 


714        DISLOCATIONS    OF    LOWER    END    OP    THE    TIBIA. 

and  German  surgeons,  speak  of  these  dislocations  as  belonging  to  tlie 
foot;  consequently  the  outward  dislocation  of  Boyer  is  the  inward 
dislocation  of  Sir  Astley  Cooper,  Malgaigne,  myself,  and  others,  who 
prefer  to  regard  the  tibia  as  the  bone  dislocated. 

§  1.  Dislocations  of  the  Lower  End  of  the  Tibia  Inwards. 

Syn. — "  Inward  tibio-tarsal  luxations  ;"  Malgaigne.      "  Dislocations  of  the  foot 
outwards;"  Boyer  and  others. 

Causes. — This  dislocation  is  occasioned  generally  by  a  fall  from  a 
height,  upon  the  bottom  of  the  foot,  the  foot  receiving  at  the  same 
moment  a  sufficient  inclination  outwards  to  determine  the  main  force 
of  the  impulse  towards  the  inner  side  of  the  ankle.  It  may  be  pro- 
duced also  by  a  blow  received  directly  upon  the  outside  of  the  leg 
just  above  the  ankle,  or  by  a  violent  twist  or  wrench  of  the  foot  out- 
wards. 

Pathohgical  Anatomy. — I  have  already,  in  the  chapter  on  fractures 
of  the  fibula,  stated  my  opinion  that  a  large  majority  of  those  acci- 
dents which  have  been  called  inward  and  outward  dislocations  of  the 
tibia,  were  merely  examples  of  lateral  rotation  of  the  astragalus  within 
the  half  ginglimoid  and  half  orbicular  socket  formed  by  the  lower 
extremities  of  the  tibia  and  fibula;  and  that  true  dislocations,  either 
partial  or  complete,  are  at  this  joint  and  in  these  directions  very  rare 
occurrences.  We  shall  continue,  however,  in  accordance  with  the 
general  practice  of  writers,  to  call  them  all  dislocations,  whether  the 
astragalus  simply  rotates  on  its  axis,  or  is  displaced  laterally  and  hori- 
zontall}'  from  the  tibia. 

In  the  most  common  form  of  the  accident,  then,  when  the  foot  is 
violently  twisted  outwards,  the  astragalus  becomes  tilted  upon  its  outer 

and  upper   margin  in  such  a 
Fig.  313.  way  as  that  this  margin  slides 

inwards  and  places  itself  under- 
neath the  middle  portion  of  the 
lower  articulating  surface  of  the 
tibia ;  its  upper  and  inner  mar- 
gin descends  toward  the  ex- 
tremity of  the  malleolus  iuter- 
nus,  and  the  outer  face  of  the 
astragalus  presents  obliquely 
upwards  and  outwards,  instead 
of  directly  outwards  as  it  would 
do  in  its  natural  position.  This 
cannot  occur  without  a  rupture 
Dislocation  of  the  lower  end  of  the  tibia  inwards.  of  the  internal  tibio-tarsal  liga- 
ments, or  a  fracture  of  the  mal- 
leolus internus,  or  both  ;  indeed,  a  fracture  of  the  internal  malleolus  is 
a  very  common  circumstance  in  connection  with  this  form  of  disloca- 
tion. Much  more  frequently,  however,  the  fibula  itself  gives  way  at 
a  point  within  from  two  to  five  inches  of  its  lower  extremity;  or 
sometimes  the  fracture  in  the  fibula  occurs  through  that  portion  which 


DISLOCATIONS    OF    LOWER    END    OF    TIBIA    INWARDS.      715 

forms  the  malleolus  externus.  For  more  particular  information  as  to 
the  causes  and  relative  frequency  of  these  fractures,  I  refer  the  reader 
to  the  chapter  on  fractures  of  the  fibula. 

Earely  it  happens  that,  instead  of  this  lateral  rotation  of  the  astra- 
galus, there  occurs  a  true  lateral  displacement  of  the  tibia  inwards 
upon  the  astragalus,  and  the  outer  portion  of  the  lower  articulating 
surface  of  the  tibia  comes  to  rest  upon  the  inner  portion  of  the  upper 
articulating  surface  of  the  astragalus;  or  it  may  slide  completely  off 
in  the  same  direction  ;  a  result  which  is  usually  attended  with  a  lacera- 
tion of  the  muscles  and  integuments,  converting  the  accident  into  a 
compound  dislocation.  In  some  cases  this  extreme  displacement  occurs 
without  such  lacerations. 

Fiff.  313. 


Dislocation  of  the  lower  end  of  the  tibia  inwards. 


In  this  form  of  the  accident,  the  true  lateral  luxation,  the  fibula  may 
remain  unbroken  and  undisturbed,  the  tibia  merely  having  become 
displaced  inwards ;  or  the  fibula  may  give  way  also  above  the  articula- 
tion, while  the  malleolus  internus,  and  the  internal  lateral  ligaments 
are  equally  liable  to  rupture  as  in  the  other  form  of  the  accident. 

Sometimes,  in  addition  to  these  complications,  the  lower  end  of  the 
tibia  is  found  to  be  broken  obliquely  upwards  and  outwards  from  the 
articulating  surface,  leaving  that  fragment  attached  to  the  fibula  which 
corresponds  to  the  inferior  peroneo-tibial  articulation. 

Symptoms. — The  foot  is  more  or  less  violently  abducted,  the  sole  of 
the  foot  presenting  downwards  and  outwards  instead  of  directly  down- 
wards ;  the  malleolus  internus  projects  strongly  at  the  inner  side  of 


716 


DISLOCATIONS    OF    LOWER    END    OF    THE    TIBIA. 


the  joint;  and  at  the  outer  side  there  is  a  corresponding  depression, 
generally  most  marked  a  little  above  the  articulation  near  the  point 
of  fracture  in  the  fibula.  The  pain  is  very  great,  and  the  foot  is 
immovably  fixed  so  far  as  the  volition  of  the  patient  can  determine 
motion,  but  the  surgeon  can  generally  move  it  pretty  freely,  yet  not 
without  causing  a  great  increase  of  the  pain.  When  the  dislocation 
is  complete,  and  the  fibula  also  is  broken,  the  limb  becomes  slightly 
shortened. 

Treatment. — When  the  accident  is  of  the  nature  of  a  simple  rotation 
of  the  astragalus  upon  its  axis,  the  reduction  is  often  accomplished 
with  the  greatest  ease  by  seizing  upon  the  foot  and  forcibly  adducting 
it.  Not  unfrequently  the  patient  himself,  or  some  other  person  who 
is  present,  has  efi'ected  the  reduction  before  the  surgeon  is  called.  In 
other  cases,  and  especially  when  it  partakes  of  the  nature  of  a  true 
dislocation,  much  difficulty  is  sometimes  experienced  in  the  reduction. 
The  surgeon  ought  then  to  flex  the  leg  upon  the  thigh,  in  order  to 
relax  the  gastrocnemii  muscles,  and  holding  the  foot  midway  be- 
tween flexion  and  extension,  he  should  pull  steadily  upon  it  with  his 


own  hands,  while  an  assistant  makes  counter-extension  and  supports 
the  limb  with  his  hands,  grasping  the  thigh  above  the  knee.  At  the 
same  moment  lateral  pressure  should  be  made  upon  the  projecting 
bone  in  the  direction  of  the  articulation.  It  is  of  some  use,  also,  to 
occasionally  flex  and  extend  the  limb  moderately,  and  to  give  to  the 
foot  a  gentle  rocking  motion.  If  more  force  is  needed,  it  may  be  ap- 
plied by  placing  the  limb  over  a  firm  double-inclined  fracture-splint, 
and  making  the  extension  by  the  aid  of  a  screw  attached  to  the  foot- 
board, as  we  have  suggested  in  certain  cases  of  dislocation  at  the  knee. 
Or  we  may  employ  the  pulleys  after  the  manner  represented  in  the 
accompanying  drawing. 

Charles  Sauer,  aged  about  thirty  years,  while  carrying  a  weight 
upon  his  shoulders,  on  the  6th  of  May,  1854,  slipped  upon  the  side- 
walk, and  fell,  dislocating  the  left  tibia  inwards,  and  fracturing  the 
fibula  four  inches  from  its  lower  end.     I  was  in  attendance  soon  after 


DISLOCATIONS    OF    LO\YER    END    OF    TIBIA    IXWARDS.      7i7 

the  accident  occurred,  and  found  the  tibia  projecting  inwards,  with 
the  other  symptoms  usually  accompanying  a  simple  rotation  of  the 
astragalus  upon  its  axis.  Seizing  the  foot  with  my  hands,  and  flex- 
ing the  leg,  while  an  assistant  held  up  the  thigh  and  made  counter- 
extension,  I  had  scarcely  begun  to  pull  upon  the  foot  before  the  re- 
duction was  effected.  Dupuytren's  splint  was  at  once  applied,  and 
the  subsequent  inflammation  was  so  trivial  as  scarcely  to  deserve 
notice.  In  six  weeks  the  limb  was  sound,  and  free  from  all  anchy- 
losis. 

In  my  report  on  dislocations,  made  to  the  New  York  State  Medical 
Society  for  the  year  1855, 1  have  mentioned  twelve  similar  examples, 
in  addition  to  some  examples  of  compound  dislocations,  all  of  which 
were  easily  reduced,  but  the  results  were  not  always  so  favorable. 

If,  as  rarely  happens,  the  tibia  is  broken  obliquely  into  the  joint, 
the  complete  reduction  of  the  dislocated  tibia  may  be  found  impos- 
sible, owing  to  the  obstacle  presented  by  the  displaced  fragment. 

The  following  I  am  disposed  to  regard  as  examples  of  dislocation 
accompanied  with  fracture  of  the  tibia  within  the  articulation : — 

Brockway,  of  Cortland,  N.  Y.,  aged  about  twenty-seven  years,  con- 
sulted me  at  my  office,  a  few  years  since,  in  relation  to  the  condition  of 
his  foot.  I  found  the  tibia  dislocated  inwards,  and  projecting  more 
than  an  inch  beyond  the  astragalus;  the  sole  was  turned  outwards, 
compelling  him  to  walk  upon  the  inside  of  his  foot ;  the  fibula  was 
bent  inwards  against  the  tibia,  at  a  point  about  four  inches  above  the 
ankle,  which  seemed  to  have  been  the  seat  of  fracture  of  this  bone. 
He  stated  to  me  that  immediately  after  the  receipt  of  the  injury, 
which  was  occasioned  by  a  fall  from  a  height  upon  the  bottom  of  his 
foot,  he  had  consulted  a  surgeon.  Dr.  A.  B.  Shipman,  of  Cortland, 
and  that  although  Dr.  Shipman  made  repeated  and  violent  eSbrts  to 
effect  the  reduction,  he  had  been  unable  to  do  so.  Indeed,  the  bone 
had  never  been  removed  from  the  position  in  which  it  was  at  first 
placed. 

J.  Borland,  of  Erie  Co.,  N.  Y.,  set.  31,  fell  under  a  rolling  log,  and 
dislocated  his  left  tibia  inwards,  breaking  off  the  internal  malleolus, 
and  fracturing  the  fibula  four  inches  from  its  lower  end.  Dr.  Sweet- 
land,  an  old  and  experienced  practitioner,  was  immediately  called,  who, 
with  another  surgeon,  failed,  after  repeated  efforts,  to  reduce  the 
dislocation.  I  saw  the  patient,  in  consultation  with  these  gentlemen, 
twenty-four  hours  after  the  accident.  The  foot  and  ankle  were  some- 
what swollen,  and  discolored.  The  lower  end  of  the  tibia  projected 
so  far  inwards  as  to  threaten  a  rupture  of  the  skin ;  the  foot  was 
strongly  everted.  We  first  flexed  the  leg  upon  the  thigh,  and  made 
extension  with  our  hands,  in  the  manner  I  have  already  directed. 
This  we  continued  several  minutes;  finally  moving  the  limb  in  various 
directions,  and  adding  forcible  pressure  upon  the  inside  of  the  pro- 
jecting tibia.  We  then  placed  the  leg  over  a  double-inclined  plane, 
and,  securing  it  firmly  in  place,  we  attached  a  screw  to  the  foot  through  a 
sandal  and  gaiter,  and  while  the  leg  was  well  flexed  upon  the  thigh,  we 
renewed  the  extension  and  lateral  pressure.  This  was  continued,  with 
the  application  of  more  or  less  power,  during  half  an  hour,  meanwhile 


718         DISLOCATIONS    OF    LOWER    END    OF    THE    TIBIA. 

changing  the  position  of  the  limb  occasionally  by  varying  the  angle 
of  the  splint.  Our  efforts  were  prolonged  in  all  more  than  one  hour, 
when,  as  we  had  made  no  impression  upon  the  bone,  and  the  patient  had 
repeatedly  implored  us  to  desist,  the  attempt  was  given  over.  The 
end  of  the  tibia  seemed  to  rest  partly  upon  the  astragalus,  and  the 
extension  was  plainly  all  that  was  demanded,  but  the  obstacle  was 
beyond  doubt  within  the  articulation,  or  rather  between  the  tibia  and 
fibula. 

Four  weeks  after  the  accident,  Mr.  Borland  walked  on  crutches, 
and  during  a  year  he  was  compelled  to  use  a  cane,  but  since  that  time, 
a  period  of  twelve  years,  he  has  walked  without  any  artificial  support. 
For  a  year  or  two  he  felt  a  yielding  in  his  ankle,  as  the  weight  of  his 
body  settled  upon  his  limb;  but  this  gradually  ceased,  and  for  some 
years  past  he  has  walked  without  any  halt,  and  seems  to  step  as  firmly 
as  before  the  accident.  The  foot  still  inclines  outwards ;  the  tibia 
projects  inwards  one  inch,  and  the  broken  ends  of  the  fibula  can  be 
felt  resting  against  the  tibia,  where  they  are  reunited. 

Not  long  since,  I  had  occasion  to  amputate  a  limb  for  a  compound 
dislocation  inwards  at  the  ankle-joint,  and  the  possibility  of  this  frac- 
ture was  confirmed  by  the  dissection.  About  one-third  of  the  outer 
portion  of  the  articular  surface  was  broken  off'  obliquely,  and  the 
fragment  was  lying  so  displaced  that  a  reduction  would  have  been 
rendered  impossible. 

Dr.  Townsend,  of  Boston,  has  reported  a  case  of  compound  dislo- 
cation, in  which  also  amputation  became  necessary ;  and,  with  other 
injuries,  the  dissection  showed  a  fragment  from  the  outer  margin  of 
the  tibia,  one  inch  and  a  half  long,  and  one  inch  thick  at  its  widest 
part,  with  a  very  sharp  point,  displaced,  and  lying  almost  transversely 
over  the  astragalus.' 

For  a  more  full  account  of  the  prognosis  and  the  general  manage- 
ment of  these  cases  subsequent  to  the  reduction,  I  beg  again  to  refer 
the  reader  to  the  chapter  on  fractures  of  the  fibula ;  and  for  my  views 
in  relation  to  the  treatment  of  compound  dislocations  of  the  ankle-joint, 
I  will  refer  also  to  the  chapter  on  compound  dislocations  of  the  long 
bones. 

§  2.  Dislocations  op  the  Lower  End  op  the  Tibia  Outwards. 

8yn. — "Outward  tibio-tarsal  luxation;"  Malgaigne.  " Dislocations  of  the  foot 
inwards,"  of  others. 

The  causes  are  the  same  or  similar  to  those  which  are  known  gen- 
erally to  produce  dislocations  inwards;  only  that  the  force  of  the 
concussion  or  the  direction  of  the  rotation  must  have  been  reversed. 

The  external  lateral  ligaments,  peroneo-tarsal,  are  either  ruptured, 
or  the  lower  portion  of  the  fibula  gives  way,  or  both  of  these  circum- 
stances may  have  happened;  while  the  internal  malleolus  may  also 
yield  to  the  shock  and  to  the  weight  of  the  body  now  resting  upon  it. 

'  Townsend,  Mass.  Hosp.  Reports,  Boston  Med.  and  Surg.  Journ.,  vol.  xxxiii. 
p.  277. 


OF    LOWER    END    OF    TIBIA    OUTWARDS. 


719 


The  nature  of  the  accident  may  Fi.s:.  315. 

vary  also  in  respect  to  the  rela- 
tive position  of  the  articular  sur- 
faces; the  astragalus  may  simply 
rotate  on  its  inner  and  upper 
margin,  or  the  tibia,  with  the 
fibula  of  course,  may  actually 
slide  outwards  until  the  lower 
end  of  the  tibia  more  or  less 
completely  abandons  the  upper 
surface  of  the  astragalus. 

The  modes  of  reduction,  and 
the  general  principles  of  treat- 
ment subsequently,  will  not 
differ  from  those  which  we  have 
mentioned  as  suitable  for  dis- 
locations in  the  opposite  direc- 
tion. The  examples  which  have 
fallen  under  my  observation  are 
not  numerous,  but  the  reduction 
has  always  been  easily  efiected. 
Thus,  a  man,  get.  21,  fell  from  a 
scaffolding,  alighting  upon  his 
feet.  He  says  that  his  left  foot 
struck  the  ground  obliquely 
and  upon  its  outer  margin.  I 
found  the  fibula  projecting  very 
strongly  outwards,  evidently 
carrying  with  it  the  tibia ;  the 
malleolus  internus  was  broken 

off,  and  the  foot  forcibly  turned  inwards.  "Without  either  flexing  the 
leg  upon  the  thigh  or  calling  to  my  aid  any  degree  of  counter-exten- 
sion except  what  was  made  by  the  weight  of  the  body,  I  grasped  the 
foot  and  drew  upon  it  gently,  while  at  the  same  moment  I  rotated  the 
foot  outwards.     Immediately  the  bones  resumed  their  places. 

In  June  of  1846,  Henry  Wilson,  get.  38,  consulted  me  in  relation  to 
his  foot,  which  he  said  had  been  dislocated  four  weeks  before.  He 
had  fallen  upon  the  outside  of  his  foot  and  turned  it  suddenly  inwards, 
so  that  when  he  looked  at  it  he  found  the  sole  presenting  toward  the 
opposite  side.  Seizing  upon  it  with  both  hands,  he  pressed  it  forcibly 
outwards,  and  the  reduction  immediately  took  place  with  a  snap. 
Very  little  soreness  followed,  nor  was  he  confined  to  his  house  a  single 
day.  He  had  continued  to  walk  about  with  only  a  slight  halt  in  his 
gait,  nor  would  he  have  thought  it  necessary  to  consult  me  at  all  ex- 
cept that  the  tenderness  had  not  yet  disappeared.  He  was  not  aware 
that  the  fibula  had  been  broken  also,  until  I  called  his  attention  to  the 
fact.  The  fracture  had  taken  place  two  inches  above  the  ankle ;  and 
although  it  was  already  united,  the  depression  occasioned  by  its  having 
fallen  in  somewhat  toward  the  tibia  was  very  plainly  felt  and  recog- 
nized. 


Dislocatioa  of  the  lower  end  of  the  tibia  outwards. 


720         DISLOCATIONS    OF    LOWEK    END    OF    THE    TIBIA. 

§  3.  Dislocations  of  the  Lower  End  of  the  Tibia  Forwards. 

^j,n.— "Forward  tibio-tarsal  luxations;"  Malgaigne.     "Dislocations  of  tlie  foot         ^ 
backwards,"  of  others. 

Causes. — This  dislocation  may  be  produced  by  a  violent  extension 
of  the  foot  upon  the  leg;  as,  for  example,  when,  the  foot  being  en- 
gaged under  a  piece  of  timber,  the  body  falls  backwards  to  the  ground ; 
or  when,  the  leg  remaining  fixed,  a  heavy  weight  descends  upon  the 
foot,  the  foot  resting  upon  an  inclined  plane;  by  a  blow  upon  the 
front  of  the  foot;  or  it  may  be  caused  by  a  fall  upon  the  bottom  or 
back  of  the  tibia,  or  possibly  even  by  the  toes  being  brought  violently 
in  contact  with  some  firm  body.  No  doubt  it  may  be  caused  also  by 
any  of  that  class  of  accidents  which  are  known  to  produce  fractures 
of  the  fibula  with  fracture  of  the  malleolus  internus,  or  fracture  of  the 
fibula  with  rupture  of  the  internal  lateral  ligament ;  for  example,  by 
a  fall  upon  the  bottom  of  the  foot,  or  upon  the  inside  of  the  sole, 
followed  immediately  by  an  outward  twist  of  the  foot.  In  these  cases 
the  luxation  of  the  foot  backwards,  or,  as  it  is  generally  found  to  be, 
the  serai-luxation,  may  be  consecutive  upon  the  accident,  and  the 
result  only  of  the  contraction  of  the  gastrocnemii.  It  may,  therefore, 
occur  immediately  after  the  fracture  has  taken  place,  or  not  until 
after  the  lapse  of  several  days. 

Pathological  Anatomy. — The  displacement  may  be  very  slight,  so 
that  the  end  of  the  tibia  is  only  a  little  advanced  upon  the  astragalus  ; 
or  it  may  be  such  that  the  tibia  rests  one-half  upon  the  naviculare 
and  one-half  upon  the  astragalus,  or  it  may  even  desert  the  astragalus 
entirely.  The  fibula  may  at  the  same  time  be  broken  at  any  point, 
but  it  is  generally  broken  two  or  three  inches  above  its  lower  ex- 
tremity. The  malleolus  internus  is  also  sometimes  broken,  but  more 
often  the  internal  lateral  ligament  is  torn.  Still  more  rarely  a  fracture 
occurs  through  the  posterior  margin  of  the  articular  surface  of  the 
tibia. 

Symptoms. — The  length  of  the  foot  in  front  of  the  tibia  is  dimin- 
ished, while  the  projection  of  the  heel  is  correspondingly  increased ; 
the  toes  are  turned  downwards  and  the  heel  drawn  upwards,  and  fixed 
in  this  position;  the  end  of  the  tibia  may  generally  be  distinctly  felt 
in  front  of  the  astragalus;  the  extensor  tendons  of  the  toes  are  sharply 
defined,  while  the  tendo-Achillis  is  curved  forwards,  and  tense. 

At  the  regular  meeting  of  the  New  York  Pathological  Society, 
Nov.  22,  1865,  I  presented  a  specimen  obtained  from  the  dissecting- 
room  of  the  Bellevue  Hospital  College.  The  history  of  the  case  was 
unknown. 

Before  dissection,  the  foot  was  observed  to  be  turned  outwards,  and 
shortened  in  front  of  the  tibia,  while  there  was  a  corresponding  length- 
ening of  the  heel.  The  specimen,  after  dissection,  disclosed  a  fracture 
of  the  internal  malleolus  half  an  inch  above  its  lower  end,  and  a  frac- 
ture of  the  fibula  a  little  above  its  lower  end.  The  tibia  was  displaced 
forwards  about  three-quarters  of  an  inch,  so  that  only  the  posterior 
half  of  its  lower  end  rested  upon  the  articular  surface  of  the  astragalus, 
and  at  the  point  of  contact  with  the  astragalus  a  new  socket  was 


OF    LOWER    END    OF    TIBIA    FORWARDS.  721 

formed  in  the  tibia,  concave  upwards,  half  an  inch  deep,  and  pre- 
senting an  appearance  as  if  the  posterior  lip  of  the  lower  end  of  the 
tibia  had  been  broken  off  and  had  become  displaced  upwards.  It  was 
supported  by  a  broad  buttress  of  bone.     It  is  not  certain,  however, 

Fig.  316.  Fig.  317. 


Partial  dislocation  of  the   tibia  forwards,  Partial  dislocation  of   the   tibia  forwards,   with 

with  fractures  of  malleolus   internus,  and  fracture  of  the  malleolus  internus,  and  fibula. 

fibula.    Skeleton. 

but  that  this  appearance  was  occasioned  solely  by  the  long-continued 
pressure  of  the  tibia  upon  the  astragalus  at  this  point.  The  fragments 
of  the  malleolus  internus,  and  the  lower  fragment  of  the  fibula,  re- 
mained attached  to  their  upper  fragments  and  to  the  two  sides  of  the 
astragalus  in  their  normal  positions,  consequently  each  fragment  was 
inclined  downwards  and  backwards  at  an  angle  of  45°.  The  lower 
fragment  of  the  fibula  was  driven  upwards,  also,  but  both  of  the  frac- 
tures were  firmly  united.  This  specimen  is  now  in  the  museum  of 
the  Bellevue  Hospital  College. 

At  the  same  meeting  of  the  Pathological  Society  I  reported  the  case 
of  Mary  Conlan,  »t.  38,  admitted  to  Bellevue  Hospital,  Nov.  13th, 
1865,  having  been  thrown  three  days  before  from  a  street  car.  She 
could  give  no  account  of  the  manner  in  which  she  fell.  I  saw  her 
Nov.  16th.  The  limb  was  then  much  swollen,  and  I  diagnosticated  a 
fracture  of  the  lower  end  of  the  fibula.  (It  had  been  supposed  to  be 
a  mere  sprain  up  to  this  time.)  The  limb  was  directed  to  be  wet  with 
cool  water,  and  to  rest  upon  a  pillow.  From  this  time  I  looked  at  it 
occasionally,  to  see  whether  the  swelling  had  sufficiently  subsided  to 
warrant  the  application  of  a  splint.  Nov.  20th  it  was  examined  again 
carefully  by  the  house  surgeon.  Dr.  Farrall,  but  no  displacement  was 
noticed.  Nov.  23d  I  found  the  lower  end  of  the  tibia  displaced  for- 
wards, and  ascertained,  also,  that  the  internal  malleolus  was  broken  at 
its  base.  The  dorsum  of  the  foot,  measuring  from  the  front  of  the 
tibia  to  the  end  of  the  great  toe,  was  shortened  half  an  inch.  The 
heel  was  lengthened. 

There  can  be  no  doubt  but  in  this  case  the  dislocation  occurred  sub- 
sequent to  the  fracture,  and  that  it  was  caused  by  the  contraction  of 
the  gastrocnemii.     I  reduced  the  dislocation  a  day  or  two  later,  and 


722         DISLOCATIONS    OF    LOWER    END    OF    THE    TIBIA. 

maintained  it  in  position  by  the  method  which  I  shall  presently  de- 
scribe. 

Dr.  Voss  reported  to  the  Society  a  similar  case  which  had  come 
under  his  notice,  and  Dr.  Buck  remarked  that  he  also  had  met  with 
such  examples.' 

Dr.  Prince,  of  Illinois,  has  reported  a  case  of  this  character,  which, 
remaining  displaced,  led  to  a  prosecution  for  damages.  A  lady,  set. 
40,  met  with  an  accident,  Aug.  31,  1863,  which  resulted  in  a  fracture 
of  the  fibula  near  its  lower  end,  and  a  partial  dislocation  of  the  tibia 
forwards  to  the  extent  of  one  inch.  The  toes  were  not  pointed  down- 
wards, but  the  foot  had  its  natural  angle  with  the  leg.  Nearly  three 
months  after  the  accident,  Dr.  Prince,  assisted  by  two  other  surgeons, 
broke  up  the  adhesions,  and  reduced  the  bones  to  their  natural  posi- 
tions.^ 

Treatment. — The  reduction  is  to  be  attempted  by  flexing  the  leg 
upon  the  thigh,  and  making  extension  from  the  foot,  while,  at  the 
same  moment,  pressure  is  made  upon  the  front  of  the  tibia  and  against 
the  heel.  When  the  bone  begins  to  slide  into  place,  the  foot  should 
be  forcibly  flexed  upon  the  leg.  A  slight  lateral  motion  or  rotation 
in  either  direction  may  assist  in  restoring  the  bones  to  place. 

In  general,  the  dislocation  has  been  easily  reduced,  but  in  a  ma- 
jority of  the  examples  recorded  great  difficulty  has  been  experienced 
in  maintaining  the  reduction ;  and  in  a  few  cases  it  has  been  found 
impossible  to  do  so. 

In  order  to  maintain  the  reduction,  the  leg,  flexed  upon  the  thigh, 
should  be  laid  on  its  back  in  a  box;  and  the  foot  supported  firmly 
against  a  foot-piece  placed  at  a  right  angle  with  the  box.  In  this 
position,  the  weight  of  the  leg  will  tend  somewhat  to  overcome  the 
action  of  the  muscles  which  are  disposed  to  displace  the  foot  back- 
wards. Generally  it  will  be  found  necessary  to  make  additional  pres- 
sure directly  upon  the  front  of  the  leg  above  the  ankle ;  which,  in 
order  that  it  may  not  prove  mischievous,  must  be  effected  with  some 
soft  material,  and  must  be  applied  over  a  broad  surface.  Perhaps 
nothing  will  better  answer  these  indications  than  to  pass  a  cotton  band, 
six  or  eight  inches  in  width,  through  slits  or  mortises  in  the  sides  of 
the  box ;  these  slits  being  of  a  width  equal  to  the  width  of  the  band, 
and  placed  at  a  point  sufficiently  below  the  level  of  the  spine  of  the 
tibia,  so  that  when  the  band  is  made  fast  underneath  the  box,  it  shall 
press  the  leg  firmly  backwards.  To  prevent  the  heel  from  suffering 
in  consequence  of  this  pressure,  it  also  should  be  supported,  or  sus- 
pended by  another  band  passing  underneath  the  heel  and  fastened 
above  to  the  top  of  the  foot-board.  The  plaster-of- Paris  dressing,  also, 
answers  the  purpose  exceedingly  well  in  these  cases. 

Dupuytren  relates  the  following  example  of  this  accident : — 

Pierre  Froment,  set.  33,  was  carrying  a  heavy  weight  upon  his  back 
and  had  his  right  foot  in  advance,  when  by  accident  he  came  suddenly 

'  New  York  Journ.  Med.,  April,  1866,  p.  40. 

2  Cincinnati  Journ.  Med.,  April,  1867,  p.  202.  See  also  Todd's  Cyclopedia  of 
Anat.  and  Pliys.;  Adams  on  Ankle-joint,  p.  160  et  seq. 


OF    LOWER    END    OF    TIBIA    FORWARDS,  723 

in  contact  with  a  beam  placed  across  his  path.  Under  the  fear  of 
being  precipitated  forwards,  he  made  a  sudden  effort  to  throw  his  body 
backwards,  by  which  he  lost  his  balance,  and  fell  with  the  point  of 
the  left  foot  inclined  inwards  and  forwards,  and  his  whole  weight  was 
thrown  first  on  the  outer  side,' and  then  on  the  front  of  the  ankle- 
joint. 

On  examination,  the  leg  seemed  to  be  planted  upon  the  middle  of 
the  foot ;  the  toes  were  directed  downwards  and  the  heel  drawn  up. 
On  the  instep  there  was  a  large  bony  prominence,  over  which  the  ex- 
tensor tendons  of  the  toes  were  stretched  like  tense  cords.  Behind  the 
joint  was  a  deep  hollow,  at  the  bottom  of  which  the  tendo-Achillis 
could  be  felt  forming  a  tense,  resisting,  semicircular  cord,  with  its  con- 
cavity directed  backwards,.  The  fibula  was  also  broken  ;  the  lower 
end  of  the  lower  fragment  remaining  attached  to  the  foot,  while  the 
upper  end  of  the  same  fragment  was  carried  forwards  by  the  displace- 
ment of  the  tibia,  so  that  it  lay  nearly  horizontally,  with  its  broken 
extremity  directed  forwards, 

Dupuytren  directed  one  assistant  to  fix  the  leg,  and  a  second  to 
make  extension  from  the  foot,  while  Dupuytren  himself,  standing  on 
the  outer  side  of  the  limb,  forced  the  heel  forwards  and  the  tibia  back- 
wards. The  first  attempt  succeeded  partially,  and  the  second  com- 
pleted the  reduction.  The  limb  was  then  placed  in  the  apparatus 
employed  by  this  surgeon  for  a  fractured  fibula,  which  we  have  before 
described,  and  laid  on  its  outer  side  in  a  semiflexed  position.  The 
patient  recovered  rapidly,  and  in  little  more  than  a  month  he  was  able 
to  walk.^ 

But  such  fortunate  results  have  not  usually  been  observed;  indeed, 
Dupuytren  encountered  much  more  serious  difficulties  in  two  other 
cases  which  came  under  his  own  notice,  one  of  which  he  has  himself 
recorded.  This  was  in  the  person  of  a  woman  set.  48,  who  was  brought 
to  the  Hotel  Dieu  in  1815,  the  accident  having  just  happened  from  a 
slip  in  going  down  stairs.  The  fibula  was  broken,  and  also  a  frag- 
ment was  broken  from  the  tibia.  The  house  surgeon  reduced  the 
bones,  and  placed  the  limb  in  the  ordinary  apparatus  for  broken  legs; 
but  on  the  following  day  Dupuytren  found  them  reluxated,  and  laid 
the  limb  on  his  own  splint,  but  the  pressure  requisite  to  keep  the  tibia 
in  place  soon  induced  sloughing,  ulceration,  and  abscesses,  and  after 
four  months'  treatment,  during  which  time  the  tibia  had  been  repeat- 
edly displaced,  she  left  the  hospital,  able  to  use  her  limb,  but  with  a 
certain  amount  of  incurable  deformity.^ 

Malgaigne  mentions  the  third  example  as  having  been  seen  by 
himself  in  Dupuytren's  service  in  1832,  in  which  case  the  attempt  to 
maintain  the  reduction  by  a  tourniquet  resulted  in  gangrene  and 
finally  the  death  of  the  patient.^  Earle  lost  a  patient  after  amputation 
made  on  the  eighth  day.  The  tibia  could  not  be  kept  in  place,  and 
the  amputation  became  necessary  on  account  of  the  final  protrusion 
of  the  bone  through  the  integuments,  which  had  sloughed.'* 

'  Dupuytren,  Injuries  and  Dis.  of  Bones,  London  ed.,  p.  278. 
2  Op.  cit.,  p.  276.  3  Malgaigne,  op.  cit.,  p.  1044 

*  Malgaigne,  op.  cit.,  p.  1044. 


724         DISLOCATIONS    OF    LOWER    END    OF    THE    TIBIA. 


§  4.  Dislocations  op  the  Lower  End  of  the  Tibia  Backwards. 

Spn.—^^  Backward  tibio-tarsal  luxations  ;"  Malgaigne.    "  Dislocations  of  the  foot 
forwards,"  of  others. 

More  rare  than  the  dislocations  forwards,  Malgaigne  has,  neverthe- 
less, succeeded  in  collecting  five  examples. 

They  appear  to  have  been  produced,  generally,  by  a  cause  the  re- 
verse of  that  which  we  have  seen  to  produce  in  certain  cases  the  pre- 
ceding dislocation.  Thus,  while  the  dislocation  forwards  is  produced 
sometimes  when  the  foot  is  in  violent  extension,  this  dislocation  has 
occurred,  in  at  least  two  or  three  cases,  when  the  foot  was  forcibly 
flexed  upon  the  leg. 

The  symptoms  are  strongly  marked  and.characteristic.  The  length 
of  the  foot  from  the  tibia  to  the  ends  of  the  toes  is  increased  one  inch 
or  more;  the  heel  being  correspondingly  shortened,  or  rather  wholly 
obliterated;  a  portion  of  the  articulating  surface  of  the  astragalus 
may  be  distinctly  felt  in  front  of  the  tibia;  the  posterior  surface  of 
the  tibia  touches  the  tendo-Achillis  ;  the  leg  is  shortened,  and  the  mal- 
leoli approach  the  sole  of  the  foot. 

In  most  cases  one  or  both  of  the  malleoli  have  been  broken ;  and 
K.  W.  Smith,  who  has  reported  one  of  the  examples  alluded  to,  be- 
lieves that  the  dislocation  is  never  complete.  ; 


Fiff.  318. 


Fig.  319. 


Dislocations  of  the  lower  ead  of  the  tibia  backwards. 

Eeduction  should  be  attempted  by  a  method  similar  to  that  which 
has  been  recommended  in  all  the  other  dislocations  of  the  ankle ;  only 
with  such  modifications  as  the  peculiarities  of  the  case  must  neces- 
sarily suggest. 


UPPEE    END    OF    THE    FIBULA    FORWAEDS  725 


CHAPTER   XX. 

DISLOCATIONS  OF  THE  UPPER  END  OF  THE  FIBULA. 

Syn. — "Luxations  of  the  superior  peroneo-tibial  articulation;"  Malgaigne. 

SuEGEONS  have  frequently  described  a  condition  of  the  peroneo- 
tibial articulation  in  which  the  ligaments  have  become  relaxed,  giving 
a  preternatural  mobility  to  the  head  of  the  bone.  It  is  also  not  unfre- 
quently  displaced  upwards,  in  consequence  of  an  oblique  fracture  of 
the  tibia.  I  have  myself  seen  several  examples  of  both  these  acci- 
dents; but  simple  traumatic  dislocations,  which  can  only  occur  for- 
wards or  backwards,  are  very  rare. 

§  I .  Dislocations  of  the  Upper  End  op  the  Fibula  Forwards. 

Malgaigne  has  collected  three  examples  of  this  luxation,  uncom- 
plicated with  any  other  accident,  and  not,  apparently,  due  to  any  ab- 
normal condition  of  the  ligaments,  two  of  which,  at  least,  seemed  to 
have  been  produced  by  the  violent  action  of  the  muscles  which  are 
attached  to  the  anterior  face  of  the  fibula.  The  third  example,  re- 
ported by  Thompson  in  the  London  Lancet,^  permits  a  doubt  as  to 
whether  the  displacement  was  occasioned  by  muscular  action,  or  by 
a  direct  blow  upon  the  part. 

The  signs  which  characterize  the  anterior  luxation  are  the  absence 
of  the  head  of  the  fibula  in  its  natural  position,  and  its  presence  in 
front,  near  the  ligamentum  patellfB ;  the  altered  direction  of  the  biceps 
flexor  cruris  muscle ;  and,  in  one  case,  considerable  deformity  in  the 
shape  and  position  of  the  leg  has  been  observed. 

Thompson  and  Jobard  were  unable  to  accomplish  the  reduction 
while  the  leg  was  extended  upon  the  thigh,  but  succeeded  readily 
after  having  flexed  the  leg.  On  the  other  hand,  Savournin  succeeded 
with  the  leg  extended,  but  with  the  foot  flexed  upon  the  leg.  Mal- 
gaigne, to  whom  I  am  indebted  for  these  observations,  thinks  that 
flexion  of  the  leg,  combined  with  flexion  of  the  foot,  would^  render 
the  reduction  more  easy. 

In  whatever  position  the  limb  is  placed,  the  surgeon  must  rely 
chiefly  upon  forcible  pressure  made  with  the  fingers  against  the  front 
and  upper  portion  of  the  displaced  bone. 

J.  B.  Hawley,  of  Ithaca,  N.  Y.,  late  Prof,  of  Surgery  in  the  Geneva 
Medical  College,  has  furnished  me  with  a  brief  account  of  a  case 
which  came  under  his  own  observation. 

On  the  29th  of  March,  1854,  Bambak,  while  vaulting  upon  the 

1  Op.  cit.,  1850,  vol.  i.  p.  385 


726       DISLOCATIONS    OF    THE    UPPER    EXD    OF    FIBULA. 

parallel  bars  in  a  gymnasium,  unintentionally  made  a  complete  somer- 
set, and  fell  with  bis  right  foot  upon  the  edge  of  a  plank.  Dr.  Hawley, 
who  was  immediately  called,  found  his  right  leg  semi-flexed  and  im- 
movably fixed.  The  head  of  the  fibula  was  plainly  felt  in  front  of 
its  natural  position,  near  the  ligamentum  patellte.  The  patient  was 
suffering  the  most  intense  pain.  Extension  and  counter-extension 
were  made,  and  while  the  doctor  was  pressing  with  both  of  his  thumbs 
upon  the  head  of  the  fibula,  it  went  into  its  place  with  an  audible 
snap.  The  relief  was  instantaneous.  Complete  rest  was  observed 
for  a  few  days,  while  cooling  lotions  were  constantly  applied,  and 
within  a  week  he  was  able  to  attend  to  his  usual  duties. 

§  2.  Dislocations  of  the  Upper  End  of  the  Fibula  Backwards. 

Sanson  has  recorded  one  example,  in  which  the  passage  of  the 
wheel  of  a  carriage  across  the  upper  part  of  the  leg,  precisely  on  a 
level  with  the  peroneo-tibial  articulation,  ruptured  the  ligaments  which 
bind  the  fibula  to  the  tibia,  and  caused  a  displacement,  which,  however, 
seems  to  have  been  spontaneously  overcome.  Nevertheless,  there  re- 
mained a  preternatural  mobility,  permitting  the  fibula  to  be  pushed 
easily  backwards  or  forwards  upon  the  tibia. 

I  have  found  only  two  other  cases  of  backward  dislocation,  one  of 
which  is  related  by  Dubreuil.  A  man,  set.  62,  in  order  to  save  him- 
self from  falling,  sprang  suddenly,  with  his  right  leg  in  a  position  of 
extreme  abduction,  and  at  the  same  moment  he  experienced  a  severe 
pain  in  the  region  of  the  peroneo-tibial  articulation.  The  head  of  the 
fibula  was  found  to  be  thrown  backwards,  and  formed  under  the  skin 
a  marked  prominence ;  the  foot  was  drawn  outwards,  and  the  whole 
outside  of  the  limb  became  cold  and  numb.  Dubreuil  flexed  the  leg 
moderately,  and  pressing  the  head  of  the  fibula  from  behind  forwards, 
the  reduction  was  easily  effected.  On  the  following  day,  the  limb 
having  been  straightened,  the  dislocation  was  found  to  be  reproduced. 
It  was  again  replaced,  and  the  knee  covered  with  a  leather  cap,  secured 
moderately  tight.  After  twelve  days  of  complete  rest,  the  knee  was 
moved  gently,  and  on  the  seventeenth  day  the  patient  walked  with 
the  help  of  a  cane.  For  some  time  the  leg  had  a  tendency  to  incline 
outwards;  but  in  about  three  months  the  cure  was  perfectly  estab- 
lished.i 

It  is  probable  that  in  this  case  the  dislocation  resulted  from  the 
violent  action  of  the  biceps  flexor  cruris.  Such,  at  least,  is  the  opinion 
of  both  Dubreuil  and  Malgaigne,  and  I  see  no  reason  to  question  the 
correctness  of  their  theory. 

The  other  example  has  been  reported  by  Dr.  Jos.  G.  Richardson, 
resident  physician  to  the  Pennsylvania  Hospital.  John  Dixon,  set.  9, 
fell  five  feet  and  struck  upon  the  outside  of  the  left  knee.  When  ad- 
mitted to  the  hospital,  the  leg  was  partially  flexed  and  the  toes  a  little 
everted,  and  he  was  unable  to  flex  or  to  extend  the  limb  completely. 
The  head  of  the  fibula  was  seen  three-quarters  of  an  inch  behind  its 

'  Malgaigne,  op.  cit.,  torn.  ii.  p.  386. 


DISLOCATIONS    OF    THE    ASTEAGALUS.  727 

natural  position,  and  the  biceps  was  felt  distinctly  attached.  There 
was  no  other  lesion.  The  reduction  was  easily  accomplished  by  press- 
ing with  the  fingers  upon  the  inner  and  back  part  of  the  fibula, 
thrusting  it  outwards  and  forwards.  A  compress  and  bandage  were 
applied,  and  the  limb  placed  at  rest.  The  reduction  continued  com- 
plete, and  after  a  few  days  he  was  permitted  to  use  the  limb.^ 


CHAPTER   XXI. 

DISLOCATIONS  OF  THE  INFERIOR  PERONEO-TIBIAL 
ARTICULATION. 

Nelaton  relates  the  only  example  of  a  simple  luxation  of  this 
articulation  of  which  we  have  any  information.  The  patient  who  was 
the  subject  of  this  accident  presented  himself  at  the  hospital  under  the 
care  of  M.  Gerdy  on  the  thirty-ninth  day  after  the  accident,  which  had 
been  occasioned  by  the  passage  of  the  wheel  of  a  carriage  obliquely 
across  the  leg  in  such  a  manner  as  to  push  the  malleolus  externus 
directly  backwards.  The  lower  end  of  the  fibula  was  in  almost  direct 
contact  with  the  outer  margin  of  the  tendo-Achillis  ;  the  outer  face  of 
the  astragalus,  abandoned  by  the  fibula,  could  be  distinctly  felt  in 
nearly  its  whole  extent ;  the  foot  preserved  its  natural  position ;  and 
he  could  walk  pretty  well,  only  that  he  was  obliged  to  step  with  some 
care.  M.  Gerdy  believed  that  the  bone  was  too  firmly  fixed  in  its  new 
position  to  be  moved,  and  therefore  made  no  attempt  at  reduction. 


CHAPTER    XXII. 

tarsal  luxations. 

§  1.  Dislocations  of  the  Astragalus. 

Malgaigne,  who  speaks  also  of  luxations  "  sub-astragaloid,"  has 
thought  proper  to  call  the  dislocations  which  we  now  propose  to 
consider,  "double  dislocations  of  the  astragalus."  In  the  variety  first 
named,  the  astragalus  retains  its  connections  with  the  tibia,  but  sepa- 
rates from  the  scaphoid  bone,  while  its  relations  to  the  calcaneum  are 
only  slightly  disturbed.  This  we  prefer  to  regard  as  one  of  the  many 
varieties  of  tarsal  luxations,  and  shall  appropriate  to  it  no  specific 
appellation,  except  to  designate  it  as  astragalo-scaphoid  or  astragalo- 
calcaneo-scaphoid,  according  as  more  or  less  of  the  several  articula- 
tions are  disturbed. 

1  Richardson,  Amer.  Journ.  Med.  Sci.,  April,  1863. 


728 


TARSAL    LUXATIONS. 


Fi?.  320. 


In  the  second  named  variety,  called  by  Malgaigne  a  "  double"  luxa- 
tion, and  which  constitutes  the  subject  of  this  chapter,  the  astraga- 
lus abandons  all  the  articular  surfaces  against  which  it  is  naturally 
applied,  and  thrusts  itself  out  from  between  the  tibia,  fibula,  cal- 
caneum,  and  scaphoides;  so  that  it  may  be  said  to  have  suffered  a 
triple  or  quadruple  rather  than  a  "double"  dislocation,  as  is  implied 
by  the  nomenclature  adopted  by  Malgaigne.  This  we  choose  to  regard 
as  the  only  true  dislocation  of  the  astragalus,  and  as  such  we  propose 
to  designate  it  by  the  simple  term  "  dislocation  of  the  astragalus." 

The  astragalus  may  be  dislocated  forwards,  outwards,  inwards,  back- 
wards ;  or  it  may  be  dislocated  obliquely  in  either  of  the  diagonals 
between  these  lines ;  it  may  be  simply  rotated  upon  its  lateral  axis, 
without  much,  if  any,  lateral  displacement ;  and,  finally,  it  has  been 

occasionally  driven  be- 
tween the  tibia  and  fibu- 
la, tearing  away  the  in- 
termediate ligaments,  and 
generally  fracturing  one 
or  both  bones  of  the  leg.  ■ 
Causes. — The  causes 
which  have  been  found 
chiefly  operative  in  the 
production  of  this  dislo- 
cation are  very  much  the 
same  as  those  which  pro- 
duce, under  other  circum- 
stances, a  dislocation  of 
the  lower  end  of  the  tibia. 
Thus,  a  fall  from  a  height  upon  the  bottom  of  the  foot,  accompanied 
with  a  violent  abduction,  adduction,  flexion,  or  extension,  may  deter- 
mine a  dislocation  of  the  astragalus  inwards,  outwards,  backwards,  or 
forwards.  Sometimes  it  is  accomplished  by  a  mere  wrenching  and 
twisting  of  the  foot  in  machinery,  or  in  the  wheel  of  a  carriage,  or  by 
being  caught  between  two  irregular  bodies.  It  may  be  produced  also 
by  a  direct  blow. 

Symptoms. — The  great  prominence  occasioned  by  the  displacement 
of  the  bone  in  either  of  these  several  directions,  accompanied  gene- 
rally with  more  or  less  lateral  deviation  of  the  foot,  is  alone  sufficient 
to  indicate  the  true  nature  of  the  accident.  In  some  cases,  also,  the 
foot  is  forcibly  flexed  or  extended ;  the  leg  is  shortened  in  conse- 
quence of  the  tibia  having  fallen  down  upon  the  calcaneum  ;  the  super- 
incumbent skin  and  tendons  are  rendered  tense;  blood  is  effused,  and 
swelling  speedily  occurs.  In  the  backward  dislocation,  the  position 
of  the  foot  is  not  much  changed,  but  the  tibia  being  slightly  carried 
forwards,  the  length  of  the  dorsal  aspect  of  the  foot  is  proportionably 
diminished. 

Such  are  the  symptoms  which  plainly  enough  indicate  the  dislo- 
cation in  the  most  simple  cases;  but  in  a  majority  of  the  examples 
which  have  been  seen,  the  integuments  have  been  more  or  less  exten- 


Dislocation  of  astragalus  outwards.     Anatomical  relations. 


DISLOCATIONS    OF    THE    ASTRAGALUS. 


729 


sively  torn,  exposing  to  the  eye  at  once  the  naked  bone,  and  thus 
removing  all  chance  of  error  in  the  diagnosis. 

Norris  mentions  a  case,  seen  by  Hammersley,  in  which  the  astra- 
galus was  thrown  completely  out,  and  was  subsequently  found  in  the 
earth  where  the  patient  had  received  his  injury.  Inflammation,  gan- 
grene, and  tetanus  supervened,  and  the  patient  died  on  the  seventh 
day.' 


Fio;.  321. 


Fio:.  323. 


Simple  dislocations  of  the  astragalus  outwards. 


Compound  dislocation  of  the  astragalus  inwards. 


Prognosis. — It  will  be  readily  understood  that  nothing  short  of  very 
great  violence  could  disturb  and  completely  break  up  the  connections 
of  a  bone  so  compactly  and  firmly  seated  as  is  the  astragalus,  and 
that,  aside  of  any  unusual  complications,  under  the  most  favorable 
circumstances,  intense  inflammation  must  naturally  be  anticipated ; 
and,  with  few  exceptions,  this  has  actually  taken  place.  Even  when 
reduction  has  been  promptly  and  easily  eS'ected,  inflammation,  gan- 
grene, and  death  have  sometimes  speedily  ensued.  But  more  often  the 
reduction  has  been  found  to  be  exceedingly  difficult  or  impossible,  and 
complete  removal  of  the  bone  or  amputation  has  been  immediately 
demanded. 

In  a  limited  number  of  cases,  on  the  other  hand,  the  bone  has  been- 
easily  reduced,  and  recovery  has  taken  place,  with  a  tolerably  useful 
limb;  or  resection  has  been  practised  with  an  equall}^  favorable  result^ 
in  still  other  cases  the  bone  has  been  left  protruding,  and  the  patient 
has  finally  recovered  so  far  as  to  be  able  to  walk  again,  but  in  such 
a  crippled  condition  as  to  render  the  achievement  a  very  doubtfal 
triumph  of  conservative  surgery. 


47 


'  Norris,  Amer.  Journ.  Med.  Sci.,  1837,  p.  383. 


730  TARSAL    LUXATIONS. 

Norris,  of  Philadelphia,  relates  the  following  case,  illustrating  the 
imminent  danger  to  which  even  the  life  of  the  patient  may  be  ex- 
posed in  those  examples  which  are  apparently  the  most  simple. 

William  Summerill,  est.  30,  was  admitted  to  the  Pennsylvania 
Hospital  on  the  twenty-sixth  of  September,  1831.  An  hour  previous, 
while  descending  a  ladder,  he  slipped  and  fell  in  such  a  manner  as  to 
throw  the  entire  weight  of  his  body  upon  the  outer  part  of  his  left 
foot.  The  foot  was  turned  inwards,  and  nearly  immovable ;  a  slight 
depression  existed  immediately  below  the  lower  end  of  the  tibia,  and 
there  was  a  hard  rounded  projection  on  the  outer  part  of  the  foot,  a 
little  below  and  in  front  of  the  extremity  of  the  fibula ;  the  skin  over 
this  projection  was  not  broken  or  excoriated,  but  reddened ;  there  was 
no  fracture  of  either  bone  of  the  leg. 

The  symptoms  rendered  it  plain  that  the  astragalus  was  dislocated 
forwards  and  outwards.  Dr.  Barton,  under  whose  care  the  patient 
was  received,  proceeded  soon  after  to  make  attempts  at  reduction. 
The  muscles  of  the  leg  were  relaxed  as  much  as  possible,  and  exten- 
sion made  from  the  foot  by  seizing  the  heel  and  front  part  of  the  foot 
while  an  assistant  made  counter-extension  at  the  knee.  The  bone  was 
also  pushed  inwards  toward  the  joint  by  the  surgeon.  These  efibrts 
were  continued  for  a  considerable  time,  but  had  no  eflfect  in  changing 
the  position  of  the  bone. 

Six  hours  afterwards,  Drs.  Harris  and  Hewson  being  in  consulta- 
tion, the  attempt  was  again  made  to  accomplish  the  reduction,  but 
without  success;  and  the  surgeons  immediately  proceeded  to  excise 
the  bone. 

An  incision  was  made  parallel  with  the  tendons,  commencing  a 
short  distance  above  the  projection,  and  extending  down  far  enough  to 
expose  fairly  the  astragalus  and  its  torn  ligaments.  The  bone  was 
then  seized  with  the  forceps  and  easily  removed  after  the  division  of 
a  few  ligamentous  fibres  that  continued  to  connect  it  with  the  adjoin- 
ing parts.  Very  little  bleeding  occurred,  only  two  small  arteries  re- 
quiring the  ligature. 

After  removal,  it  was  discovered  that  about  one-half  of  the  surface 
which  plays  in  the  lower  end  of  the  tibia  had  been  fractured,  and  that 
it  remained  firmly  attached  to  the  extremity  of  that  bone.  No  at- 
tempt was  made  to  remove  this  fragment;  but,  the  joint  being  care- 
fully sponged  out,  the  sides  of  the  wound  were  brought  together  and 
closed  by  sutures,  adhesive  straps,  and  a  roller ;  after  which  the  foot, 
placed  in  its  natural  position,  was  laid  in  a  fracture-box. 

On  the  fifth  day  a  slough  began  to  form  upon  the  outside  of  the 
foot,  which  was  followed  by  suppuration  at  other  points,  and  on  the 
thirteenth  day  an  opening  was  made  to  evacuate  the  pus  near  the 
malleolus  internus.  At  the  end  of  about  eight  weeks  the  fragment 
of  the  astragalus  which  had  been  suflered  to  remain  was  found  to  be 
carious,  and  it  was  removed ;  the  heel  also  had  ulcerated  from  pres- 
sure, and  several  other  bones  of  the  tarsus  were  discovered  to  be  ca- 
rious. Fifteen  months  later,  this  poor  fellow  was  still  in  the  hospital, 
suffering  from  hectic,  with  extensive  disease  in  the  bones  of  the  tar- 


DISLOCATIONS    OF    THE    ASTRAGALUS.  731 

sus  and  ankle-joint.     Finally,  anaputation  of  the  leg  was  practised  by 
Dr.  Barton,  a  few  days  after  which  he  died^ 

Norris  mentions  also  two  examples  of  simple  dislocation  of  the  as- 
tragalus at  the  Pennsylvania  Hospital  which  came  under  the  obser- 
vation of  Dr.  Barton,  in  both  of  which  the  bone  was  left  unreduced. 
In  one  case  inflammation  and  sloughing  soon  effected  a  complete  ex- 
posure of  the  protruding  bone,  but  after  a  time  the  skin  cicatrized.  At 
the  end  of  five  months  the  patient  walked  and  had  good  use  of  the 
joint,  though  great  deformity  of  the  foot  existed,  and  he  continued  to 
be  subject  to  ulceration  of  the  newly-formed  skin  on  its  outer  part. 
In  the  other  case  gangrene  supervened  soon  after  the  accident,  and 
the  patient  died. 

Norris  adds  that  "  the  late  Professor  Wistar  removed  the  astragalus 
in  a  case  of  compound  dislocation,  and  the  patient  was  cured  with 
some  motion  at  the  joint," 

Dr.  Alexander  Stevens,  of  New  York,  made  the  same  operation  in 
a  case  of  compound  dislocation,  and,  after  several  months,  he  affirms 
that  the  patient  "  has  recovered  with  very  trifling  deformity  of  the 
foot,  and  with  a  flexible  joint.     He  walks  with  very  slight  lameness."^ 

I  am  indebted  to  Dr.  B.  H.  Hart,  of  Marietta,  Ohio,  for  an  account 
of  the  following  case,  and  for  the  specimen,  which  has,  also,  kindly 
been  put  in  my  possession. 

In  June,  1853,  Thomas  Williams  was  thrown  from  his  carriage, 
alighting  upon  his  left  foot  and  causing  a  compound  dislocation  of  the 
ankle-joint.  Dr.  Hart  was  immediately  called,  and  found  the  bones 
of  the  leg  thrust  through  the  integuments  on  the  outside,  the  malleo- 
lus internus  broken,  and  the  astragalus  partially  dislocated.  After 
enlarging  the  opening  in  the  integuments  with  a  pocket-knife,  the 
doctor  was  able  to  reduce  the  dislocated  bones  to  place.  It  must  be 
mentioned  that  this  man  weighed  225  lbs.,  and  that  in  his  fall  he  de- 
scended a  precipice  or  bank  30  feet  in  height.  Soon  after  the  reduc- 
tion the  patient  had  two  severe  convulsions,  which  were  arrested  by 
bleeding  and  opiates,  and  never  returned.  Cool  lotions  were  applied 
to  the  limb ;  and  on  the  sixth  day  erysipelas  supervened  and  extended 
nearly  to  the  body.  The  erysipelas  continued  about  nine  days.  Ex- 
tensive suppuration  throughout  the  joint  resulted,  and  some  fragments 
of  bone  came  away,  and  oq  the  thirty-third  day  Dr.  Hart  removed, 
without  the  aid  of  the  knife,  the  entire  astragalus.  In  three  months 
the  patient  walked  upon  crutches,  and  in  eleven  months  he  could  walk 
well  without  a  staff",  a  slight  motion  having  been  preserved  in  the 
ankle  joint. 

The  dislocations  backwards,  of  which  seven  examples  only  have 
been  recorded,  have  all,  with  but  one  exception,  been  left  unreduced; 
yet  in  at  least  four  instances  the  patients  have  recovered  with  pretty 
useful  limbs.  Such  was  the  fact  with  Liston's  and  Lizar's  patients, 
and  also  with  Mr.  Phillips'  two  cases,  to  all  of  which  I  shall  again 
refer.     It  must  be  noticed,  however,  that  in  each  of  the  cases  raen- 

>  Norris,  Amer.  Journ.  Med.  Sci.,  Aug.  1837,  p.  378. 

2  Stevens,  North  Amer.  Med.  and  Surg.  .Jouru.,  Jun.  1S27.  p.  200. 


732  TARSAL    LUXATIONS. 

tioned  as  followed  by  a  successful  termination  without  reduction,  the 
dislocations  were  simple. 

Turner,  of  Manchester,  has  reported  one  example  of  compound 
luxation  outwards  and  backwards,  in  which,  finding  himself  unable 
to  effect  reduction,  he  removed  the  astragalus,  with  a  tolerably  success- 
ful result.'  Finally,  a  case  was  presented  in  one  of  the  London  hos- 
pitals in  1889,  of  a  dislocation  inwards  and  backwards,  which  was 
reduced  in  about  ten  minutes,  by  extension  accompanied  with  lateral 
pressure.^ 

In  Sept.  Ib70, 1  saw,  with  Dr.  Sayre,  in  consultation,  a  dislocation  of 
the  astragalus  forwards  and  outwards,  in  the  person  of  Mr.  Stewart, 
of  this  city,  which  had  just  occurred  in  consequence  of  an  injury  re- 
ceived in  being  thrown  from  a  carriage.  The  dislocation  seemed  to 
be  nearly  complete,  causing  great  projection  and  tension  of  the  skin. 
Under  the  influence  of  chloroform,  by  extension  and  pressure,  it  was 
easily  reduced  by  Dr.  Sayre.  In  five  weeks  from  this  time  he  was 
able  to  walk,  and  soon  after  the  restoration  of  the  functions  of  the 
joint  was  complete. 

Treatment. — Various  attempts  have  been  made  by  surgical  writers 
to  determine  the  line  of  treatment  which  should  be  adopted  in  these 
unfortunate  cases,  but  with  very  unsatisfactory  results,  since  they  are 
far  from  having  arrived  at  similar  conclusions,  nor  have  they  been 
able  always  to  settle  the  question  definitely  for  themselves.  The  diffi- 
culty consists  in  the  multiplicity  and  lack  of  uniformity  in  the  com- 
plications which  attend  these  accidents,  rendering  it  impossible  to 
establish  a  classification  upon  which  a  uniform  treatment  may  be 
safely  based.  There  are  certain  principles,  however,  which  seem  to 
be  sufficiently  settled  to  allow  of  an  authoritative  announcement; 
these  may  be  briefly  stated  as  follows:  If  the  dislocation  is  simple, 
reduce  the  astragalus  immediately,  provided  this  is  possible.  If  the 
luxation  is  complete,  and  it  cannot  be  reduced,  even  partially,  proceed 
at  once  to  resection  or  to  amputation.  In  compound  dislocations,  re- 
section or  amputation  affords  the  only  safe  resource.  In  all  cases  the 
inflammation  is  likely  to  be  intense,  in  order  to  prevent  which  com- 
plication the  surgeon  must  be  unremitting  in  his  use  of  the  appropri- 
ate remedies. 

Out  of  eighteen  cases  of  complete  excision  of  the  astragalus,  collected 
by  Turner,  fourteen  made  good  recoveries,  and  in  only  one  of  these 
fourteen  was  there  anchylosis. 

The  several  indications  and  rules  of  treatment  above  enumerated 
we  shall  proceed  to  illustrate  a  little  more  fully. 

In  a  recent  simple  luxation  of  the  astragalus  forwards,  the  leg 
should  be  flexed  to  a  right  angle  with  the  thigh,  and,  for  the  purpose 
of  making  extension,  one  assistant  should  take  hold  of  the  foot  with 
both  hands  in  the  same  manner  that  a  servant  draws  a  boot,  that  is, 
with  the  right  hand  grasping  the  heel,  and  the  left  placed  upon  the 

'  Turner,  Traus.  Provin.  Med.  and  Surg.  Journ.,  vol.  ix.  Essay  on  Disloc.  of 
Astrag..  with  nearly  fifty  cases.  For  additional  cases,  see  Med.  and  feurg.  Reporter, 
Jan.  18G7. 

2  London  Lancet,  vol.  ii.  p.  559. 


DISLOCATIONS    OF    THE    ASTRAGALUS.  783 

dorsum  of  the  foot,  near  the  toes.  A  second  assistant  should  sei^ie  the 
lower  part  of  the  thigh,  in  order  to  make  counter-extension,  while  the 
surgeon  presses  with  the  ball  of  his  hand  against  the  head  of  the  as- 
tragalus, upwards  and  backwards.  If  these  simple  measures  fail,  the 
pulleys  ought  to  be  employed  as  a  substitute  for  the  hands  in  making 
extension.  In  applying  the  extension,  the  toes  m.ust  be  kept  well 
down,  and  occasionally  the  foot  should  be  moved  gently  from  one  side 
to  the  other. 

An  oblique  dislocation  must  be  reduced,  if  possible,  to  an  anterior 
luxation,  before  an  attempt  is  made  to  carry  the  head  of  the  bone  back 
to  its  place,  as  by  this  mode  the  reduction  will  be  greatly  facilitated. 

Lateral  luxations  may  be  reduced  by  the  same  means ;  but  if  the 
astragalus  is  dislocated  outwards,  the  foot  must  be  held  forcibly  ad- 
ducted  during  the  extension;  and  if  it  is  dislocated  inwards,  the  foot 
must  be  held  strongly  in  the  opposite  direction, 

Lizars  says  that  he  has  seen  one  case  of  backward  luxation,  and 
that  all  attempts  at  reduction  were  unavailing.  The  limb  was,  how- 
ever, preserved,  and  proved  to  be  useful,^  Liston  was  equally  un- 
successful in  a  case  which  came  under  his  notice,^  Phillips  has 
reported  two  cases,  in  neither  of  which  was  the  reduction  accom- 
plished.^ Nelaton  has  seen  a  compound  dislocation  which  he  could 
not  reduce."*  Mr.  Brichsen,  however,  who  admits  that  when  dislocated 
backwards  it  has  not  hitherto  been  reduced,  declares  that  the  surgeons 
at  University  Hospital  have  succeeded  in  one  case  recently,  in  which 
both  the  tibia  and  fibula  were  broken  also.''  Mr.  Erichsen  sus-o-ests 
also  that,  in  case  of  a  failure  by  the  ordinary  means,  we  should  resort 
to  a  subcutaneous  section  of  the  tendo-Achillis.  Mr.  Williams,  of 
Dublin,  in  a  similar  case,  which  had  been  left  unreduced,  was  obliged 
finally  to  extract  the  bone,  in  consequence  of  the  integuments  having 
sloughed.^ 

Compound  dislocations,  and  such  as  are  otherwise  complicated, 
demand  of  the  surgeon  immediate  amputation  or  exsection,  the  latter 
of  which  ought  to  be  preferred  whenever  the  condition  of  the  limb 
encourages  a  reasonable  hope  that  the  foot  may  be  saved. 

Dr.  Grant,  of  Canada,  has  recently  reported  a  case,  however,  of  suc- 
cess after  reduction  of  a  compound  dislocation  of  this  bone.  The  man 
was  35  years  old,  and  in  good  health.  Immediately  after  the  ac(5ident 
the  astragalus  was  found  completely  dislocated  forwards,  and  lying 
with  its  long  axis  placed  transversely,  so  that  the  anterior  extremity 
protruded  through  the  integuments  one  inch  on  the  outer  side  of  the 
foot.  There  was  no  fracture.  The  first  attempt  at  reduction,  by  ex- 
tension and  pressure,  failed ;  but  in  the  second  attempt  moderate 
pressure,  without  extension,  was  successful.  Suppuration  ensued,  and 
continued  two  months.     At  the  end  of  eight  months  he  walked  with- 

'  Lizars,  System  of  Practical  Surg.,  Edinburgh  ed.,  1847,  p.  161. 

2  Liston,  Elements  of  Surgery,  vol.  iii.  p.  348. 

3  Phillips,  Lond.  Med.  Gaz.,  vol.  xiv.  p.  596. 
''  Nelaton,  Pathologic  Chirurg.,  t.  ii.  p.  483. 

5  Erichsen,  Science  and  Art  of  Surg.,  Amer.  ed.,  1850,  p.  270. 
^  Williams,  Erichsen,  op.  cit.,  p.  271. 


734  TAESAL    LUXATIONS. 

out  a  cane ;  and  at  the  date  of  the  report  the  ankle  was  in  all  respects 
perfect,^ 

When  exsection  is  practised,  and  the  bone  is  found  to  be  broken, 
as  it  often  is,  all  the  fragments  should  be  carefully  removed,  since 
they  are  certain  to  become  necrosed  if  left  in  place.  Nor  ought  the 
surgeon  to  hesitate  to  lay  open  freely  the  tissues  in  every  direction,_  in 
order  that  he  may  accomplish  this  purpose ;  even  the  tendons  lying 
over  the  protruding  bone  may  be  sacrificed  unhesitatingly,  since,  after 
having  been  so  severely  bruised,  stretched,  and  lacerated,  they  are 
pretty  certain  to  slough.  Indeed,  the  more  freely  the  tissues  are 
divided  over  the  bone,  the  less  will  be  the  danger  of  inflammation, 
and  the  safer  will  be  the  life  and  limb  of  the  patient. 

In  addition  to  the  examples  already  cited  of  compound  dislocation 
in  which  the  astragalus  was  removed,  the  following,  reported  by  Dr. 
W.  A.  Gillespie,  of  EUisville,  Ya.,  will  also  illustrate  the  occasional 
value  of  exsection  in  these  severe  accidents. 

Mrs.  A.,  aged  about  fifty  years,  fell  from  a  horse  on  the  23d  of  May, 
1833,  dislocating  both  ankles.  The  luxation  of  the  right  foot  was 
accompanied  with  a  luxation  of  the  astragalus  outwards,  which  pro- 
jected through  a  very  large  wound  in  the  integuments,  and  its  trochlea 
was  placed  at  an  angle  of  about  45°  with  its  natural  position.  Early 
on  the  following  day  it  was  removed  by  severing  its  few  remaining 
connections,  and  the  wound  was  immediately  closed  by  stitches,  ad- 
hesive plasters,  and  light  dressings.  From  the  moment  of  the  receipt 
of  the  injury,  and  for  several  days  afterwards,  she  suffered  excruciating 
pain  in  the  limb,  and  on  the  third  day  tetanus  was  apprehended,  but 
its  full  accession  was  prevented  by  the  free  use  of  opiates.  The  limb 
was  suspended  in  N.  R.  Smith's  fracture-apparatus ;  and  as  gangrene 
with  hectic  fever  soon  threatened  the  life  of  the  patient,  fermenting 
j)oultices  were  diligently  applied,  and  the  patient  was  sustained  by 
wine,  bark,  and  other  tonics.  Two  months  after  the  injury  was  re- 
ceived, the  date  at  which  the  report  is  given,  the  wound  had  entirely 
healed,  and  her  complete  recovery  was  regarded  as  certain.^  Many 
other  similar  examples  have  been  reported  by  foreign  surgeons. 

One  word  more  with  regard  to  the  treatment  of  the  wound  after 
excision.  A  considerable  experience  in  accidents  and  wounds  of  this 
class,  that  is,  wounds  accompanied  with  great  contusion  and  lacera- 
tion, has  convinced  me  that  the  practice  of  closing  the  surface  with 
sutures,  adhesive  plasters,  bandages,  &c.,  is  eminently  pernicious. 
The  effusions  which  must  necessarily  occur,  and  which  indeed  we 
think  ought  to  occur,  are  thus  imprisoned  beneath  the  skin,  giving 
rise  to  swelling,  pain,  inflammation,  and  finally  suppuration  or  slough- 
ing. It  is  far  better,  in  our  opinion,  to  leave  the  wound  open,  covering 
it  only  with  cloths  constantly  kept  moist  with  cool  water.  For  this 
latter  purpose  some  mode  of  irrigation  is  preferable,  as  being  more  con- 
stant and  uniform.  To  those  who  have  never  adopted  this  treatment 
of  contused  wounds,  or  of  wounds  generally,  we  would  recommend  aa 

'  Grant,  Canada  Med.  Journ.,  Oct.  1865. 

2  Gillespie,  Amer.  Journ.  Med.  Sci.,  Aug.  1833,  p.  553. 


ASTRAGALO-CALCANEO-SCAPHOID    DISLOCATIONS.      735 

early  trial,  feeling  confident  that  they  will  never  have  occasion  to 
regret  the  experiment. 

§  2.  Astragalo-Calcaneo-Scaphoid  Dislocations. 

It  is  perhaps  quite  as  common  for  the  astragalus  to  be  dislocated 
from  the  scaphoid  bone  and  calcaneum,  while  it  retains  its  connections 
with  the  tibia,  as  to  be  luxated  from  all  these  bones  at  the  same  time. 
This  astragalo-calcaneo-scaphoid  dislocation  is  that  which  Malgaigne 
has  termed  "  sub-astragaloid."  Produced  by  the  same  causes  which 
determine  true  dislocations  of  the  astragalus,  it  may  occur  in  the  same 
directions,  and  is  liable  to  the  same  complications ;  nor  will  either  the 
prognosis  or  treatment  differ  essentially  from  that  which  is  recognized 
and  established  in  the  other  accident. 

As  in  dislocations  proper  of  the  astragalus,  so  also  in  this  accident, 
opposite  results  have  occasionally  followed  from  similar  modes  of 
treatment.  Thus,  Dr.  Detmold,  of  New  York,  stated  in  1856  to  the 
New  York  Academy  of  Medicine,  that  he  had  recently  met  with  a 
dislocation  of  the  astragalus,  in  which  the  bone  retained  its  proper 
relations  with  the  tibia,  but  not  with  the  bones  of  the  tarsus.  The 
patient  had  fallen  from  a  wagon  and  caught  his  foot  in  the  wheel. 
Dr.  Detmold  made  extension  with  pulleys,  but  could  not  effect  the 
reduction.  Subsequently  he  was  obliged  to  remove  the  astragalus  on 
account  of  the  suppuration  which  followed  and  the  consequent  exposure 
of  the  bone.  The  wound  did  not  heal  kindly,  and  at  length  amputa- 
tion of  the  leg  became  necessary. 

Dr.  Detmold  concludes,  from  this  example  and  others  which  have 
come  to  his  knowledge,  that  if  a  similar  case  were  to  present  itself  to 
him  again,  he  would  amputate  at  once.^ 

The  following  case,  reported  by  Dr.  Thomas  Wells,  of  Columbia, 
S,  C,  is  of  unusual  interest,  as  illustrating  the  danger  of  leaving  the 
bone  displaced,  and  also  the  benefit  which  may,  even  under  the  most 
unfavorable  circumstances,  result  from  its  final  removal, 

Dr,  S,,  set.  30,  was  riding  in  an  open  carriage,  some  time  during 
the  year  1819,  when  his  horses  became  frightened  and  ran,  and  m 
leaping  from  his  vehicle  he  struck  upon  his  left  foot,  dislocating  the 
astragalus  from  its  junction  with  the  scaphoid  bone,  upwards  and 
slightly  outwards.  Several  medical  gentlemen  made  violent  efforts  to 
reduce  the  bone,  but  without  effect.  Inflammation  and  suppuration, 
accompanied  by  a  high  fever,  soon  followed,  and  the  head  of  the 
astragalus  becoming  carious,  protruded  through  the  skin.  On  the 
18th  of  August,  about  seven  months  after  the  injury  was  received,  he 
was  still  suffering  from  a  copious  discharge,  pain,  swelling,  and  general 
irritative  fever,  and  it  was  determined  to  excise  the  bone ;  which  was 
accordingly  done  by  enlarging  the  wound  and  detaching  its  loose 
connections  with  the  adjacent  tissues.  The  astragalus  extracted  left  a 
frightful  wound,  the  foot  seeming  to  be  nearly  separated  from  the  leg. 
A  hollow  splint  was  adjusted  to  the  inside  of  the  foot  and  leg,  so  as  to 

'  Detmold,  New  York  Jouru.  Med.,  May,  ISoG,  p.  383. 


736  TARSAL    LUXATIOXS. 

preserve  the  limb  perfectly  steady  and  in  a  proper  direction ;  simple 
dressings  were  applied,  and  an  anodyne  administered  internally.  No 
accidents  followed,  and  at  the  end  of  September  the  wound  was  healed, 
and  the  swelling  of  the  parts  had  entirely  subsided.  One  year  after 
the  operation,  he  walked  without  the  least  difficulty ;  the  ankle  being 
then  "  perfectly  sound."  The  leg  was  shortened  about  one  inch,  and 
this  deficiency  was  supplied  by  a  thick  heel  upon  his  shoe.'  • 

Examples  might  be  cited  illustrative  of  the  value  of  early  exsection 
where  reduction  could  not  be  accomplished;  but,  after  what  has 
already  been  said  upon  the  subject  of  dislocations  of  the  astragalus, 
we  shall  not  regard  any  farther  reference  as  either  necessary  or  useful. 
If  other  principles  of  treatment  are  to  govern  the  surgeon  than  those 
which  we  have  already  laid  down,  they  cannot  here  be  stated.  They 
are  among  those  unwritten  rules  whose  existence  we  cannot  always 
recognize  until  the  case  arises  upon  which  they  may  apply.  Yet,  in 
the  exigency  supposed,  they  are  as  clearly  defined,  and  as  imperative, 
in  the  mind  of  the  clever  surgeon,  as  any  of  those  laws  which  have 
been  made  the  subjects  of  special  record. 

§  3.  Dislocations  of  the  Calcaneum. 

The  calcaneum  may,  as  a  consequence  of  a  fall  upon  the  heel,  or 
of  a  direct  blow,  be  dislocated  outwards  from  the  astragalus  alone,  or 
upwards  and  outwards  from  the  cuboid  bone  at  the  same  time.  It 
has  been  found  also  at  the  same  moment  dislocated  outwards  from  the 
astragalus  and  inwards  upon  the  cuboid  bone. 

Chelius  says  he  has  seen  an  old  dislocation  of  the  calcaneum,  pro- 
duced in  early  life  by  pulling  off  a  boot,  from  which  there  finally 
resulted  a  degeneration  like  elephantiasis  of  the  leg,  rendering  ampu- 
tation necessary  ,2 

Mr.  South  remarks,  in  his  Notes  to  Chelius,  that  the  two  cases  of 
dislocation  outwards  of  this  bone,  mentioned  by  Sir  Astley  Cooper, 
were  from  his  (South's)  Notes  (cases  199  and  200).  In  the  first  case, 
that  of  Martin  Bentley,  occasioned  by  the  falling  of  a  heavy  stone 
upon  his  foot,  the  integuments  were  not  broken,  and  the  position  of 
the  foot  resembled  a  varus.  "  The  dislocation  was  easily  reduced, 
having  bent  the  thigh  and  knee  on  the  body  and  fixed  the  leg,  by 
laying  hold  of  the  metatarsus  and  of  the  tuberosity  of  the  heel-bone, 
and  drawing  the  foot  gently  and  directly  from  the  leg,  during  which 
extension  Cline  put  his  knee  against  the  outside  of  the  joint,  and  the 
foot  being  pressed  against  it,  the  heel  and  the  navicular  bone  readily 
slipped  into  their  place,  and  the  deformity  disappeared."  He  was 
discharged  from  the  hospital  in  five  weeks,  "  having  the  complete  use 
of  his  foot." 

In  the  second  case,  the  dislocation,  produced  also  by  the  fall  of  a 
stone  upon  the  foot,  was  compound,  and  the  patient,  Thomas  Gilmore, 
having  been  brought  into  St.  Thomas's  Hospital,  the  reduction  was 

'  Wells,  Amer.  Journ.  Med.  Sci.,  May,  1832,  p.  21. 
Chelius,  System  of  Surg.,  Amer.  ed.,  vol.  ii.  p.  354. 


DISLOCATIOXS    OF    THE    OS    SCAPHOIDES.  737 

effected  by  extending  the  foot  and  rotating  it  outwards.  Six  months 
after,  when  he  left  the  hospital,  he  was  able  to  walk  pretty  well  with 
a  stick. 

§  4.  Middle  Tarsal  Dislocations. 

The  scaphoid  and  cuboid  bones  may  be  dislocated  from  the  astra- 
galus and  calcaneum,  constituting  what  is  termed,  by  Malgaigne,  a 
middle  tarsal  dislocation.  It  is  probable  that,  to  some  extent,  the  same 
thing  has  occurred  in  many  of  those  cases  which  are  reported  as  sim- 
ple dislocations  of  the  astragalus,  or  as  dislocations  at  the  astragalo- 
scaphoid  articulation ;  but  it  occurs  also  occasionally  in  a  degree  so 
perfect  and  complete  as  to  leave  no  doubt  as  to  the  true  nature  of  the 
disjunction,  and  to  entitle  it  to  a  separate  consideration. 

Mr.  Liston  mentions  the  case  of  a  boy,  ast.  14,  who  fell  from  a  height 
of  forty  feet,  striking,  apparently,  upon  the  extremity  of  the  foot. 
The  scaphoid  and  cuboid  bones  were  found  to  be  displaced  upwards 
and  forwards,  so  that  the  foot  was  shortened  about  half  an  inch,  and 
had  a  clubbed  appearance.  No  attempt  was  made  to  reduce  the  bones, 
and  he  left  the  hospital  in  three  weeks,  able  to  stand  on  the  foot.^  Sir 
Astley  Cooper  has  recorded  in  more  detail  a  similar  example.  A  man, 
working  at  the  Southwark  bridge.  London,  received  upon  the  top  of 
his  foot  a  stone  of  great  weight.  He  was  immediately  carried  to  Guy's 
Hospital,  and  his  condition  is  described  as  follows :  "The  os  calcis 
and  the  astragalus  remained  in  their  natural  situations,  but  the  fore- 
part of  the  foot  was  turned  inwards  upon  the  bones.  When  examined 
by  the  students,  the  appearance  was  so  precisely  like  that  of  a  club- 
foot, that  they  could  not  at  first  believe  but  that  it  was  a  natural  defect 
of  that  kind;"  but,  upon  the  assurance  of  the  man  that  previously  to 
the  accident  his  foot  was  not  distorted,  extension  was  made,  and  the 
reduction  was  effected.  He  was  discharged  from  the  hospital  in  five 
weeks,  having  the  complete  use  of  his  foot.^ 

§  5.  Dislocations  of  the  Os  Cuboides. 

According  to  Piedagnel,  quoted  by  Chelius,  the  cuboid  bone  may 
be  dislocated  upwards,  inwards,  and  downwards,  but  Malgaigne  affirms 
that  he  has  found  no  case  recorded  in  which  the  dislocation  has  oc- 
curred alone,  or  unaccompanied  with  a  dislocation  of  one  or  more  of 
the  other  tarsal  bones. 

§  6.  Dislocations  op  the  Os  Scaphoides. 

Burnett  has  seen  a  luxation  of  the  scaphoid  bone  in  which  its  con- 
nections with  the  astragalus  were  undisturbed,  while  at  the  same  time 
it  was  completely  separated  from  the  cuneiform  bones.  By  strong 
pressure  exercised  during  several  minutes,  the  os  scaphoides  was 
made  to  fall  into  its  place.     The  dislocation  was  compound,  yet  the 

'  Practical  Surgery;  also  London  Lancet,  vol.  xxxvii.  p.  133. 
2  Sir  A.  Cooper  on  Dlsloc,  &c.,  Loudon  ed.,  1823,  p.  376. 


738  TARSAL    LUXATIONS. 

wound  healed  rapidly,  and  in  a  short  time  the  recovery  was  almost 
complete.^ 

Several  examples  are  recorded  of  a  true  luxation  of  the  os  sca- 
phoides,  in  which  the  bone  had  abandoned  both  the  astragalus  on  the 
one  hand,  and  the  cuneiform  bones  on  the  other. 

Piedagnel  mentions  a  case  in  which  the  scaphoid  bone  was  broken 
longitudinally,  and  its  internal  fragment,  constituting  the  largest  por- 
tion, was  displaced  inwards  through  a  tegumentary  wound.  He  was 
unable  to  effect  reduction,  and  was  compelled  to  amputate  the  foot.^ 

Walker  has  reported  the  first  example  of  luxation  forwards,  occa- 
sioned by  jumping  upon  the  ball  of  the  foot.  The  bone  formed  a 
marked  projection  upon  the  top  of  the  foot,  and  a  corresponding  de- 
pression existed  below.  An  attempt  was  first  made  to  accomplish 
the  reduction  by  simple  pressure  with  the  thumbs ;  but  this  having 
failed,  the  surgeon  bent  the  extremity  of  the  foot  forcibly  downwards, 
and  by  continuing  to  press  upon  the  os  scaphoides,  it  fell  into  its  posi- 
tion easily  and  with  a  distinct  click.  In  about  three  weeks  the  patient 
was  able  to  walk  with  only  a  slight  halt,  and  no  deformity  remained.^ 

§  7.  Dislocations  of  the  Cuneiform  Bones. 

The  cuneiform  bones  may  be  luxated  partially,  and  without  having 
separated  from  each  other,  of  which  two  or  three  examples  are  re- 
corded ;  or,  which  is  more  common,  the  cuneiforme  internum  may  be 
luxated  alone.  Says  Sir  Astley  Cooper:  "I  have  twice  seen  this 
bone  dislocated  ;  once  in  a  gentleman  who  called  upon  me  some  weeks 
after  the  accident,  and  a  second  time  in  a  case  which  occurred  in  Guy's 
Hospital  very  lately.  In  both  instances  the  same  appearances  pre- 
sented themselves.  There  was  a  great  projection  of  the  bone  inwards, 
and  some  degree  of  elevation,  from  its  being  drawn  up  by  the  action 
of  the  tibialis  anticus  muscle  ;  and  it  no  longer  remained  in  a  direct 
line  with  the  metatarsal  bone  of  the  great  toe.  In  neither  case  was 
the  bone  reduced ;  the  subject  of  the  first  of  these  accidents  walked 
with  but  little  halting,  and  I  believe  would  in  time  recover  the  use  of 
the  foot,  so  as  not  to  appear  lame.  The  cause  of  the  accident  was  a 
fall  from  a  considerable  height,  by  which  the  ligament  was  ruptured 
which  connects  this  bone  with  the  os  cuneiforme,  and  with  the  os 
naviculare.  The  second  case,  which  was  in  Guy's  Hospital,  my  ap- 
prentice, Mr,  Babington,  informs  me,  happened  by  the  fall  of  a  horse, 
and  the  foot  was  caught  between  the  horse  and  the  curb-stone."* 

In  a  case  of  compound  luxation  seen  by  Mr.  Key,  reduction  was 
effected,  and  in  two  months  the  cure  was  so  far  completed  that  the 
patient  walked  with  only  a  slight  lameness.^  N^laton,  in  a  similar 
case  of  compound  luxation,  unable  to  reduce  the  bone,  removed  it 
completely,  and  the  patient  recovered.® 

'  Burnett,  Lond.  Med.  Gazette,  1837,  vol.  xix.  p.  231. 

2  Piedagnel,  Journ.  Univ.  et  Heb.,  torn.  ii.  p.  208. 

3  Walker,  The  Medical  Examiner,  1851,  p.  203. 
*  Sir  Ast.  Cooper,  op.  cit.,  p.  383. 

s  Key,  Guy's  Hosp.  Rep.,  1836,  vol.  i.  p.  544. 
6  Nelaton,  Malgaigne,  op.  cit.,  p.  1076. 


DISLOCATION'S    OF    THE    CUNEIFORM    BONES.  739 

Eobert  Smith  has  called  attention  to  a  species  of  dislocation  of  the 
internal  cuneiform  bone  not  before  very  accurately  described ;  but  of 
which  he  has  presented  two  examples.  It  consists  in  simultaneous 
dislocation  of  the  metatarsus  and  internal  cuneiform ;  that  is  to  say,  the 
first  metatarsal  bone,  together  with  the  internal  cuneiform,  is  dislocated 
upwards  and  backwards  upon  the  tarsus,  carrying  with  it  also  the  four 
remaining  metatarsal  bones.  In  both  of  the  examples  seen  and  re- 
corded by  him,  the  dislocations  were  ancient,  and  no  account  could  be 
obtained  of  the  precise  manner  in  which  the  accidents  had  been  pro- 
duced. The  feet  were  foreshortened  to  the  extent  of  an  inch  or  more, 
in  consequence  of  the  overlapping  of  the  bones,  yet  the  heel  in  each 
case  preserved  its  natural  relations  to  the  tibia,  not  being  proportion- 
ately lengthened  as  is  the  case  in  dislocations  of  the  tibia  forwards. 
The  plantar  surface  of  the  foot  was  turned  inwards,  and  instead  of 
being  concave  it  was  convex,  both  in  its  antero-posterior  and  trans- 
verse diameters.  A  transverse  ridge  on  the  top  of  the  foot  also  indi- 
cated the  line  of  the  projecting  bones.  Both  of  these  cases  were  veri- 
fied by  a  careful  dissection.' 

Dupuytren  has  reported  in  his  Treatise  on  Injuries  of  the  Bones,  a 
similar  case,  occurring  in  a  woman,  get.  30,  who  was  brought  immedi- 
ately to  Hotel  Dieu.  She  stated  that  in  descending  from  the  bridge 
of  St.  Michael,  with  a  burden  of  two  hundred  pounds,  she  fell  in  such 
a  way  that  the  whole  weight  of  the  body  was  received  on  the  right 
foot,  and  that,  at  the  moment  she  made  an  effort  to  check  herself  in 
falling,  she  experienced  extremely  severe  pain  in  this  part,  and  heard 
a  very  distinct  snap ;  she  was  unable  to  raise  herself  from  the  ground. 
On  the  following  morning  Dupuytren  reduced  the  bones  with  very 
little  difficulty  by  extension,  combined  with  pressure  against  the  dis- 
located ends.  The  bones  went  into  place  with  a  loud  snap,  and  in 
two  or  three  months  she  left  the  hospital,  with  only  a  little  lameness.^ 

Mr.  Smith,  without  intending  to  question  the  possibility  of  a  sim- 
ple luxation  of  the  metatarsal  bones,  of  which,  indeed,  Malgaigne  has 
collected  a  number  of  well-authenticated  examples,  is  inclined  to  be- 
lieve that,  when  a  luxation  of  the  bones  of  the  metatarsus  is  the  con- 
sequence of  a  fall  from  a  height,  the  individual  alighting  upon  the 
anterior  part  of  the  foot,  it  is,  in  general,  that  variety  which  has  now 
been  described.  And  this  aptness  on  the  part  of  the  cuneiform  bone 
to  maintain  its  connection  with  the  first  metatarsal  bone,  he  would 
ascribe  mainly  to  the  fact  that  both  the  peroneus  longus  and  tibialis 
anticus  have  attachments  to  each  of  the  bones  in  question. 

•  Robert  Smith,  Treatise  on  Fractures,  &c.,  Dublin  ed.,  1854,  p.  224  et  seq. 
^  Dupuytren,  op.  cit.,  jd.  336. 


740  DISLOCATIONS    OF    THE    METATARSAL    BONES. 


CHAPTER    XXIII.  ^^ 

DISLOCATIONS  OF  THE  METATARSAL  BONES. 

Luxations  of  one  or  more  of  the  metatarsal  bones,  at  the  points 
of  their  articulations  with  the  tarsus,  have  been  known  to  occur  in 
almost  every  direction.  They  may  be  occasioned  by  crushing  acci- 
dents, by  machinery,  or  more  often  perhaps  they  have  been  caused 
by  a  fall  backwards  or  forwards  when  the  anterior  extremity  of  the 
foot  was  wedged  under  some  solid  body  and  immovably  fixed.  They 
may  be  produced  also,  probably,  by  simply  striking  upon  the  ball  of 
the  foot  in  falling  from  a  height.  We  have  noticed,  however,  that 
Mr,  Smith  inclines  to  the  opinion  that  this  will,  in  general,  only  pro- 
duce the  species  of  dislocation  which  he  has  particularly  described. 

The  symptoms  which  characterize  the  dislocation  of  the  whole 
range  of  metatarsal  bones  upwards  and  backwards  will,  when  the  dis- 
location is  complete,  resemble  very  much  those  which  belong  to  the 
dislocation  described  by  Smith.  The  dorsum  of  the  foot  will  bo 
shortened  antero-posteriorly,  the  two  arches  of  the  foot  will  be  lost 
upon  the  plantar  surface,  or  even  actually  reversed,  a  ridge  will 
traverse  the  back  of  the  foot  and  a  corresponding  depression  will 
exist  underneath. 

In  some  cases,  however,  the  dislocation  is  not  complete,  the  articu- 
lations being  only  sprung,  and  then  there  can  exist  no  foreshortening 
of  the  foot,  and  all  the  other  signs  will  be  less  striking. 

If  onl}'-  a  single  bone  is  luxated  the  diagnosis  is  generally  very 
easily  made  out,  unless  indeed  considerable  swelling  has  already  oc- 
curred. 

Mr.  South  says  that,  in  1835,  a  case  was  admitted  to  St.  Thomas's 
Hospital,  under  Mr.  Green's  care,  of  dislocation  of  the  last  two  meta- 
tarsal bones.,  occasioned  by  the  falling  of  a  heavy  chest  upon  the  inside 
of  the  foot.  Upon  the  top  of  the  foot  was  a  large  swelling  below  and 
in  front  of  the  outer  ankle,  and  behind  it  a  cavity  in  which  two  fingers 
could  be  easily  buried,  in  consequence  of  the  bases  of  the  metatarsal 
bones  having  been  thrown  upwards  and  backwards  upon  the  top  of 
the  cuboid  bone.  The  reduction  was  accomplished  with  much  diffi- 
culty by  continued  extension,  and  as  the  bones  resumed  their  place  a 
distinct  crackling  was  heard.^ 

Liston  reduced  a  dislocation  upwards  of  the  first  metatarsal  bone; 
Malgaigne  mistook  a  dislocation  of  the  fourth  bone  for  a  fracture,  and 
did  not  attempt  the  reduction  until  the  seventh  day,  when,  after  five 
successive  trials,  the  head  entered  with  a  noise  into  its  cavity.  In  a 
dislocation  of  the  second,  third,  and  fourth  metatarsal  bones,  he  also 

'  South,  Note  to  Chelius's  Surg.,  vol.  ii.  p.  2o6.  Pi\ 


DISLOCATIONS    OF    THE    METATARSAL    BONES.  7-il 

failed  to  detect  the  true  nature  of  the  accident  until  the  tenth  daj, 
when  he  proceeded  to  attempt  reduction,  but  failed.  Inflammation, 
suppuration,  and  delirium  followed,  and  the  patient  died  on  the  forty- 
first  day.  Tufnell  failed  in  a  similar  case,  although  his  patient  finally 
recovered  with  a  not  very  useful  limb.  Malgaigne  failed  to  reduce 
the  bones  also  in  a  recent  case  of  luxation  of  the  first  four  bones,  al- 
though he  used  chloroform,  and  diligently  tried  various  means.  The 
same  writer  has  seen  one  example  of  ancient  dislocation,  which  was 
not  recognized  by  the  surgeon.  Finally,  Monteggia  reports  a  case  of 
dislocation  of  the  last  two  metatarsal  bones,  which  was  not  at  the  time 
recognized.  On  the  tenth  day  swelling  commenced,  and  soon  after 
the  patient  died  in  convulsions.' 

These  references,  drawn  chiefly  from  Malgaigne,  sufficiently  illus- 
trate the  difl&culty  which  surgeons  have  experienced  in  the  reduction 
of  these  bones,  when  a  portion  only  is  displaced.  A  difficulty  which 
is  probably  due  to  the  fact  that  it  is  almost  impossible  to  make  ex- 
tension upon  a  single  metatarsal  bone;  indeed,  it  is  probable  that  by 
pressure  only  upon  the  displaced  head  can  we  expect  to  accomplish 
much  in  these  accidents,  and  even  this  cannot  be  made  to  act  very 
effectively,  owing  to  the  small  amount  of  surface  presented  against 
which  the  force  can  be  properly  applied. 

If,  on  the  other  hand,  all  the  bones  are  dislocated  at  once,  the 
reduction  is  generally  accomplished  with  ease  by  simple  extension, 
combined  with  properly  directed  pressure.  Bouchard  and  Meynier 
succeeded  without  difficulty  in  two  cases  of  backward  dislocation ; 
Smyly  was  equally  successful  on  the  sixth  day,  in  a  case  of  disloca- 
tion downwards.  Laugier  reduced  an  outward  dislocation  of  all  the 
bones  by  pressure  and  extension  easily ;  and  Kirk  succeeded  as  well, 
in  an  example  of  the  opposite  character,  all  the  bones  being  carried 
inwards.^ 

Mr.  Sandwith  has  given  us  an  account  of  a  case  which  occurred  in 
his  own  person,  from  the  fall  of  his  horse  upon  his  foot.  "  I  was  in- 
vStantly  sensible,"  says  Mr.  Sandwith,  "  of  the  nature  of  the  injury, 
and  as  soon  as  I  was  upon  my  feet,  the  metatarsus  was  found  to  be 
drawn  upwards,  and  obliquely  outwards  upon  the  tarsus,  by  the  action 
of  the  flexor  muscles.  On  the  removal  of  the  boot,  which  was  cut 
away,  these  were  the  appearances :  the  foot  considerably  shortened, 
the  toes  turned  a  little  outwards,  and  a  hard  swelling,  bigger  than  an 
egg,  upon  the  tarsus,  with  tumefaction  of  the  integuments.  Thepaiu, 
which  was  great  at  first,  was  kept  under  by  a  warm  fomentation. 

"  The  reduction  was  easily  effected  by  my  friends  Messrs.  Williams 
and  Brereton,  and  leeches  and  bread  and  water  poultices  prevented 
inflammation.  For  several  nights  the  foot  was  violently  shaken  by 
spasmodic  action  of  the  muscles,  but  the  parts  preserved  their  relative 
situation  ;  and,  although  it  was  nearly  a  year  before  all  lameness 
ceased,  yet  at  the  end  of  six  weeks  I  was  enabled  to  lay  aside  my 
crutches.  For  the  ability  to  use  the  foot  in  so  short  a  time,  I  was 
indebted  to  a  contrivance  which  rendered  the  foot  and  ankle  inflexible. 

'  Malgaigne,  op.  cit.,  1077  et  seq.  ^  Ibid.,  op.  cit.,  p.  1081. 


7-i2      DISLOCATIONS    OF    THE    PHALANGES    OF    THE    TOES. 

"  Instead  of  an  elastic  sole  to  the  shoe  part  of  the  apparatus,  one  of 
wood  was  procured,  around  the  heel  of  which  was  nailed  a  piece  of 
firm,  unbending  leather  ;  this  reached  as  high  as  the  calf  of  the  leg; 
three  small  straps  with  buckles  held  the  leg  in  situ,  and  a  broader  one 
across  the  instep  secured  the  foot.  The  comfort  I  experienced  from 
this  simple  apparatus  is  my  reason  for  describing  it  so  particularly;  it 
has  since  been  found  useful  in  various  injuries  of  the  foot  and  ankle."^ 

In  one  extraordinar}'-  case,  however,  Dupuytren  was  not  so  success- 
ful. Paul  Eudes,  set.  24,  fell,  while  drunk,  into  a  ditch  six  feet  deep, 
and  alighted  on  the  soles  of  his  feet.  The  accident  was  followed  by 
great  swelling,  and  he  did  not  suspect  the  nature  of  the  injury,  nor 
present  himself  at  the  hospital  until  three  weeks  after.  Dupuytren 
then  ascertained  that  he  had  dislocated  the  metatarsal  bones  of  both 
feet.  Several  fruitless  attempts  were  made  to  accomplish  the  reduc- 
tion, but  to  no  purpose,  and  in  about  two  weeks  he  left  the  hospital.^ 


CHAPTER   XXIV. 

DISLOCATIONS  OF  THE  PHALANGES  OF  THE  TOES. 

Dislocations  of  the  toes  are  less  common  than  those  of  the  fingers, 
yet  a  considerable  number  of  cases  have  been  recorded  by  different 
surgeons.  They  are  occasioned  by  blows  received  directly  upon  the 
ends  of  the  toes;  by  the.weight  of  the  body  brought  to  bear  suddenly 
upon  their  plantar  surfaces,  as  when  a  horseman  springs  in  his  stirrup, 
or  by  a  fall,  in  consequence  of  which  the  rider  hangs  in  his  stirrup; 
by  leaping,  &c. 

They  may  be  partial  or  complete ;  and  in  the  latter  case,  a  slight 
overlapping  is  generally  observed.  In  a  great  majority  of  cases  the 
direction  of  the  displacement  is  backwards,  or  with  only  a  slight  lateral 
deviation.  Occasionally  several  bones  are  displaced  at  the  same  time, 
but  usually  only  one  sufi'ers  displacement.  It  is  more  common  here 
to  find  compound  and  complicated  dislocations  than  in  the  case  of  the 
fingers. 

The  position  of  the  toes  is  not  always  the  same  in  the  same  form  of 
dislocations.  Thus,  in  the  dislocation  backwards,  the  toe  is  sometimes 
reversed  upon  the  foot  to  nearly  a  right  angle,  and  at  other  times  it  is 
found  lying  in  the  same  axis  as  the  metatarsal  bone,  or  the  phalanx, 
from  which  it  is  luxated.  About  one  year  since,  I  reduced  a  backward 
dislocation  of  the  first  phalanx  of  the  second  toe  in  the  person  of  Lewis 
Britton,  get.  60,  who  had  fallen  from  a  fourth-story  window,  striking 
upon  his  feet,  and  breaking  both  thighs.  I  did  not  discover  the  dislo- 
cation of  the  toe  until  sixteen  hours  after  the  accident.     It  was  then 

'  Sandwitli,  Amer.  Journ.  Med.  Sci.,  Nov.  1828,  p.  316,  from  Lond.  Med.  Gaz., 
vol.  i. 
2  Dupuytren,  op.  cit.,  p.  329. 


i 


COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES.      743 

lying  parallel  with  the  axis  of  the  metatarsal  bone,  upon  which  it  was 
slightly  overlapped.  The  reduction  was  effected  easily  by  pulling  upon 
the  last  phalanx  with  my  fingers,  while  at  the  same  moment  I  pushed 
the  head  of  the  bone  toward  the  socket.  No  swelling  followed,  nor 
has  it  troubled  him  at  all  since  his  recovery. 

With  regard  to  the  treatment,  surgeons  have  experienced  the  same 
difficulty  in  certain  cases  of  dislocation  of  the  great  toe  as  we  have 
seen  experienced  in  similar  dislocations  of  the  thumb.  Occasionally, 
indeed,  the  reduction  has  been  found  to  be  impossible.  The  same 
doubts  have  existed  also  in  relation  to  the  causes  of  this  difficulty,  and 
in  reference  to  the  means  by  which  it  was  to  be  overcome.  We  shall 
therefore  refer  the  reader  to  the  chapter  on  Dislocations  of  the  First 
Phalanges  of  the  Thumb  and  Fingers,  for  a  more  full  consideration  of 
this  matter. 

In  case  the  smaller  toes  are  luxated,  the  reduction  is  generally 
effected  with  ease,  by  simple  extension,  or  by  extension  combined  with 
pressure ;  sometimes,  also,  the  bone  will  be  more  easily  put  in  place 
by  reversing  the  phalanx  more  completely,  as  we  have  advised  in  cer- 
tain cases  of  dislocation  of  the  fingers. 

If  the  skin  is  penetrated,  it  will  often  be  found  necessary  either  to 
amputate  or  to  practise  resection  upon  the  exposed  phalanx. 

Sir  Astley  Cooper  relates  a  case  of  luxation  of  "  all  the  smaller 
toes,"  from  the  metatarsus,  which  had  not  been  reduced,  and  the  sub- 
ject of  which  was,  in  consequence,  so  much  maimed  that  he  was  unable 
to  labor.  It  had  been  occasioned  by  a  fall,  from  a  considerable  height, 
upon  the  extremities  of  the  toes.  A  projection  existed  at  the  roots  of 
all  thesmaller  toes,  the  extremity  of  each  metatarsal  bone  being  placed 
under  the  first  phalanx  of  its  corresponding  toe.  The  swelling  which 
immediately  followed  the  receipt  of  the  injury,  had  concealed  its 
nature,  and  now,  several  months  having  elapsed,  reduction  could  not 
be  effected.  The  only  relief  which  could  be  afforded  him,  therefore, 
was  in  wearing  a  piece  of  hollow  cork  at  the  bottom  of  the  inner  part 
of  the  shoe,  to  prevent  the  pressure  of  the  metatarsal  bones  upon  the 
nerves  and  bloodvessels.' 


CHAPTER    XXV. 

COMPOUND  DISLOCATIONS  OF  THE  LONG  BONES. 

Frequency  of  Compound  as  compared  with  Simple  Dislocations. — Com- 
pound dislocations,  as  compared  with  simple,  are  of  rare  occurrence. 
Of  ninety-four  dislocations  reported  by  Norris  as  having  been  re- 
ceived into  the  Pennsylvania  Hospital  for  the  ten  years  ending  in 
1840,  only  two  were  compound  f  and  of  one  hundred  and  sixty-six 

'  Sir  Ast.  Cooper,  op.  cit.,p.  385. 

2  Norris,  Amer.  Journ.  Med.  Sci.,  April,  1841,  p.  335. 


744      COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES, 

dislocations  in  my  record  of  personal  observation,  only  eight  were 
compound.^ 

Relative  Frequency  in  the  Different  Joints. — In  my  own  recorded  cases, 
four  were  dislocations  of  the  tibia  inwards  at  the  ankle-joint,  one  was 
'  a  partial  (pathological)  luxation  forwards  at  the  same  joint,  one  was  a 
luxation  of  the  astragalus,  one  a  luxation  of  the  head  of  the  humerus 
into  the  axilla,  and  one  a  forward  luxation  of  the  radius  and  ulna  at 
the  wrist-joint.  I  have  also  met  with  several  examples  of  compound 
dislocations  of  the  fingers.  Both  of  the  cases  reported  by  Norris  were 
dislocations  of  the  thumb. 

Sir  Astley  Cooper,  speaking  upon  this  point,  says  that  the  elbow, 
wrist,  ankle,  and  finger  joints  are  most  subject  to  these  accidents  ;  and 
that  he  has  seen  but  two  in  the  shoulder-joint,  and  one  in  the  knee- 
joint.  He  had  never  seen  a  compound  dislocation  at  the  hip-joint,  and 
he  believed  that  it  was  "  scarcely  ever"  so  dislocated.  Mr.  Bransby 
Cooper,  has,  however,  reported  in  detail  a  very  interesting  case  of  this 
accident  communicated  to  him  by  Dr.  Walker,  of  Charlestown,  Mass., 
in  which  reduction  was  accomplished  by  manipulation  alone,  by  Dr. 
Ingalls  on  the  second  day.  The  patient  died  at  the  end  of  about  three 
weeks.^  So  far  as  I  know,  this  is  the  only  case  upon  record.  Mal- 
gaigne  says  that  a  compound  dislocation  at  the  hip-joint  has  probably 
never  occurred. 

Among  the  cases  of  compound  dislocation  recorded  by  Sir  Astley 
and  Bransby  Cooper,  most  of  which  were  communicated  to  these  gen- 
tlemen by  other  surgeons,  45  were  dislocations  of  the  ankle,  10  of  the 
astragalus,  4  of  the  ulna  at  the  wrist-joint,  4  of  the  thumb,  2  of  the 
knee,  1  of  the  shoulder,  1  of  the  elbow,  1  of  the  radius  and,  ulna  at 
the  wrist,  1  of  the  scaphoid  bone,  and  1  of  the  metatarsal  bone  of  the 
great  toe.  Other  writers  have  occasionally  described  compound  dis- 
locations of  the  clavicle,  but  I  know  of  no  record  of  a  compound  dis- 
location of  the  lower  jaw. 

Prognosis,  as  determined  hy  the  Mode  of  Treatment  adopted  hy  most  of 
the  Ancient  and  maiiy  of  the  Modern  Surgeons. — By  most  of  the  early 
writers  these  accidents,  whenever  they  occurred  in  the  larger  joints, 
were  regarded  as  nearly  beyond  the  reach  of  art.  Says  Hippocrates : 
"In  cases  of  complete  dislocation  at  the  ankle-joint,  complicated  with 
an  external  wound,  whether  the  displacement  be  inwards  or  outwards, 
you  are  not  to  reduce  the  parts,  but  let  any  other  physician  reduce 
them  if  he  choose.  For  this  you  should  know  for  certain,  that  the 
patient  will  die  if  the  parts  are  allowed  to  remain  reduced,  and  that 
he  will  not  survive  more  than  a  few  days,  for  few  of  them  pass  the 
seventh  day,  being  cut  off  by  convulsions,  and  sometimes  the  leg  and 
foot  are  seized  with  gangrene."  Hippocrates  adds:  "But  if  not  re- 
duced, nor  any  attempt  at  first  made  to  reduce  them,  most  of  such 
cases  recover."'^ 

1  For  the  most  of  these  cases,  see  Transactions  of  the  New  York  State  Med.  Soc 
for  1855,  article  entitled  "Report  on  Dislocations,  with  especial  reference  to  their 
Results,"  by  F.  H.  Hamilton. 

2  A.  Cooper,  on  Dislocations,  &c.,  by  B.  Cooper,  p.  59. 

3  Works  of  Hippocrates,  Sydenham  ed.,  London,  vol.  ii.  p.  634. 


COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES.      7-i5 

The  same  remarks  are  applied  by  Hippocrates  to  compound  dislo- 
cations of  the  head  of  the  tibia,  of  the  lower  end  of  the  femur,  of  the 
wrist,  elbow,  and  shoulder  joints ;  death  occurring  in  all  cases,  as  he 
believes,  more  or  less  speedily  whenever  the  bones  are  reduced  and 
retained  in  place  a  sufficient  length  of  time,  and  "  were  it  not  that  the 
physician  would  be  exposed  to  censure,"  he  would  not  reduce  even 
the  bones  of  the  fingers,  since  it  must  be  expected,  he  thinks,  that 
their  articular  extremities  will  exfoliate  even  when  the  reduction  is 
most  successful. 

I  shall  presently  show,  however,  that  even  Hippocrates  advised  and 
probably  practised  resection  in  certain  cases  of  these  accidents. 

Both  Celsus  and  Galen  adopt  almost  without  qualification  the  line 
of  practice  laid  down  by  Hippocrates,  and  affirm  equally  the  danger 
and  almost  certain  death  consequent  upon  the  reduction  of  compound 
dislocations  in  large  joints.^  Celsus  recommends  resection  in  some 
cases. 

Paulus  ^gineta,  however,  and  after  him  Albucasis,  Haly  Abbas, 
and  Rhazes,  do  not  regard  the  rules  established  by  Hippocrates,  in 
relation  to  the  non-reduction  of  the  bones,  as  so  imperative,  nor  the 
results  of  the  opposite  practice  as  so  uniformly  fatal. 

"  Hippocrates  remarks,"  says  Paulus  ^gineta,  "  in  the  case  of  dis- 
locations with  a  wound,  the  utmost  discretion  is  required.  For  these, 
if  reduced,  occasion  the  most  imminent  danger,  and  sometimes  death, 
the  surrounding  nerves  and  muscles  being  inflamed  by  the  extension, 
so  that  strong  pains,  spasms,  and  acute  fevers  are  produced,  more  par- 
ticularly in  the  case  of  the  elbows,  knees,  and  joints  above,  for  the 
nearer  they  are  to  the  vital  parts  the  greater  is  the  danger  they  induce. 
Wherefore,  Hippocrates,  by  all  means,  forbids  us  to  apply  reduction 
and  strong  bandaging  to  them,  and  directs  us  to  use  only  anti-inflam- 
matory and  soothing  applications  to  them  at  the  commencement,  for 
that  by  this  treatment  life  may  sometimes  be  preserved.  But  what 
he  recommends  for  the  fingers  alone,  we  would  attempt  to  do  for  all 
the  other  joints;  at  first  and  while  the  parts  remain  free  from  inflam- 
mation, we  would  reduce  the  dislocated  joint  by  moderate  extension, 
and  if  we  succeed  in  our  object,  we  may  persist  in  using  the  anti- 
inflammatory treatment  only.  But  if  inflammation,  spasm,  or  any  of 
the  aforementioned  symptoms  come  on,  we  must  dislocate  it  again  if 
it  can  be  done  without  violence.  If,  however,  we  are  apprehensive  of 
this  danger  (for  perhaps,  if  inflammation  should  come  on,  it  will  not 
yield),  it  will  be  better  to  defer  the  reduction  of  the  greater  joints  at 
the  commencement;  and  when  the  inflammation  subsides,  which 
happens  about  the  seventh  or  ninth  day,  then,  having  foretold  the 
danger  from  reduction,  and  explained  how,  if  not  reduced,  they  will 
be  mutilated  for  life,  we  may  try  to  make  the  attempt  without  violence, 
using  also  the  lever  to  facilitate  the  process."^ 

In  the  following  quotations  from  three  of  the  most  celebrated 
writers  of  the  last  two  centuries,  we  find  but  little  if  any  evidence 

'  Paulus  ^gineta,  Syd.  ed.,  vol.  ii.  p.  510. 
2  Ibid.,  p.  509. 
48 


746      COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES. 

that  the  opinions  of  the  fathers  upon  this  subject  were  not  still  held 
in  general  respect:  "If  the  joint  be  dislocated,  so  that  it  is  either 
uncovered,  or  a  little  thrust  forth  without  the  skin,  the  accident  is 
mortal,  and  of  more  danger  to  be  reduced  than  if  it  be  not  reduced. 
For  if  it  be  not  reduced,  inflammation  will  come  upon  it,  convulsion, 
and  sometimes  death.  2.  There  will  be  a  filthiness  of  the  part  itself. 
3.  An  incurable  ulcer,  and  if  perhaps  it  be  brought  to  cicatrize  at  all, 
it  will  easily  be  dissolved  by  reason  of  the  softness  of  it ;  but  if  it 
be  reduced,  it  brings  extreme  danger  of  convulsion,  gangrene,  and 
death.'" 

"  Si  vero  in  magnis  articulis  tarn  valida  fuit  facta  luxatio,  ut  liga- 
meutis  ruptis  os  articuli  raultum  sit  protrusum  per  integumenta,  hsec 
pars  ossis  vasis  privata  moritur,  citius  autem  si  reponatur,  quam  si 
non  reponitur ;  quare  sola  amputatio  restat  ad  conservationem  vit£e."^ 

Heister,  who  makes  no  allusion  to  this  subject  in  the  first  edition 
of  his  great  w'ork,  published  at  Amsterdam  in  1739,  adds  the  following 
remarks  in  his  last  edition,  translated  and  published  in  London  in 
1768  :  "Dislocations  attended  with  a  wound,  especially  of  the  shoulder 
or  thigh-bone,  are  of  very  bad  consequence,  and  often  endanger  the 
life  of  the  patient;  in  Celsus's  opinion  (Book  YIII,,  Chap.  XXV.), 
whether  the  bones  be  replaced  or  not,  there  is  generally  great  danger; 
and  so  much  the  more  the  nearer  the  wound  is  to  the  joint.  Hippo- 
crates has  declared  that  no  bones  can  be  reduced  with  security,  beside 
those  of  the  hands  and  feet.  (  Vectiar.  19,  5.)  See  more  on  this  subject 
in  that  passage  of  Celsus  just  now  quoted,  though  I  by  no  means  re- 
commend the  following  him  implicitly."^ 

Such  were  the  extreme  views  as  to  the  fatality  of  these  accidents, 
and  of  the  feebleness  of  our  resources,  entertained  by  the  ancient,  and 
even  by  the  more  modern  writers  almost  down  to  our  own  day ;  with 
only  rare  exceptions  these  limbs  were  condemned  either  to  great  and 
inevitable  deformity,  or  to  amputation.  Nor,  if  we  speak  only  of 
their  fatality,  have  surgeons  ceased  to  regard  these  accidents  as  among 
the  most  grave  with  which  they  have  to  deal. 

Patliology  and  AiDpreciaiion  of  the  Sources  of  Danger  as  comjMi'ed 
especially  with  Compound  Fractures. — The  danger,  according  to  Sir 
Astley  Cooper,  consists  in  the  rapid  inflammation  of  the  synovial 
membranes,  which  is  speedily  followed  by  suppuration  and  ulceration 
whereby  the  ends  of  the  bones  become  exposed  ;  and  for  the  repair  of 
which  lesions  great  general  as  well  as  local  efforts  are  required,  and 
a  high  degree  of  constitutional  irritation  results.  In  addition  to  which 
circumstances,  "  the  violence  inflicted  on  the  neighboring  parts,  the 
injury  of  the  muscles  and  tendons,  and  the  laceration  of  bloodvessels, 
necessarily  lead  to  more  important  and  dangerous  consequences  than 
those  which  follow  simple  dislocations." 

The  sources  of  danger  enumerated  by  Sir  Astley  Cooper  have  been 

1  "  Chirurgeon's  Storehouse."  By  Johannes  Scultetus,  of  Ulme,  in  Suevia. 
London  ed.,  1G74,  p.  31. 

2  Johannes  de  Gorter.     Chirurgia  repurgata.     Lugduni  Batavorem,  1742,  t.  86. 

3  General  System  of  Surgery,  by  Dr.  Laurence  Heister.  8th  ed.  London,  1768. 
Vol.  i.  p.  164. 


COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES.      747 

regarded  as  sufficient  to  account  for  their  extraordinary  fatality  bv 
the  majority  of  those  modern  surgical  writers  who  have  alluded  to 
the  subject;  but  I  must  confess  that  to  me  they  do  not  appear  so.  .  In 
compound  fractures  the  mortality  is  far  less  ;  yet  one  might  naturally 
suppose,  that  when  the  sharp  and  irregular  fragments  are  pressing 
into  the  flesh,  among  nerves  and  bloodvessels,  the  irritation  and  in- 
flammation would  be  equal,  if  not  more  than  equal,  to  the  irritation 
and  consequent  inflammation  produced  by  exposing  a  joint  surface  to 
the  air;  indeed,  modern  experience  has  sufficiently  shown  that  these 
surfaces  are  much  more  tolerant  of  atmospheric  exposure,  and  of  the 
action  of  many  other  irritants,  than  surgeons  formerly  supposed.  A 
clean  incision  into  a  large  joint,  which  exposes  the  synovial  mem- 
branes to  the  air,  and  which  permits  the  products  of  inflammation  to 
escape  freely,  is  attended  with  much  less  danger  than  a  small  punc- 
ture which  does  not  at  all  permit  the  air  to  enter,  nor  the  increased 
synovia  and  the  pus  to  escape.  Very  grave  results  sometimes  follow 
from  large  wounds  into  large  joints,  but  under  judicious  treatment 
such  results  are  the  exception  and  not  the  rule.^  But  Sir  Astley  evi- 
dently attributes  more  of  the  bad  consequences  to  the  exhausting 
efiects  of  the  efforts  at  repair,  than  to  the  immediate  inflammation  re- 
sulting from  the  exposure  of  the  joint.  It  is  pretty  certain,  however, 
that  a  majority  of  these  patients  die  at  a  period  too  early  to  render 
this  cause  in  any  considerable  degree  operative. 

As  to  the  bruising  of  the  "  muscles  and  tendons,  and  laceration  of 
bloodvessels,"  it  cannot  be  denied  that  it  must  usually  be  greater  than 
in  "  simple  dislocations ;"  and  I  will  not  say  that  it  is  not  in  a  given 
number  of  instances  greater  than  in  the  same  number  of  instances  of 
compound  fractures.  The  tissues  have  often  been  thrust  rudely  through 
by  a  large  and  smooth  bone,  and  the  tendons  have  been  stretched  vio- 
lently or  torn  completely  asunder;  while  occasionally  large  arteries, 
which  are  prone  to  hug  the  bones  about  the  joints,  are  lacerated  and 
left  to  bleed.  That  the  importance  of  these  complications,  however, 
may  not  be  overestimated,  we  must  state  that  Sir  Astley  Cooper  him- 
self has  remarked  how  seldom,  in  compound  dislocations  of  the  ankle- 
joint,  the  large  arteries  are  injured ;  that  a  tearing  of  the  ligaments 
and  of  the  tendons  is  almost  as  likely  to  occur  in  simple  dislocations 
as  in  compound ;  and,  indeed,  that  in  neither  case  are  the  tendons 
usually  ruptured,  but  only  thrust  aside.  Moreover,  the  skin  is  often 
made  to  give  way  not  so  much  from  the  pressure  of  the  round  head 
within,  as  from  the  equal  pressure  of  some  sharp  angular  body  from 
without.  In  all  these  respects,  there  are  many  examples  of  compound 
fractures  which  possess  not  a  whit  of  advantage ;  in  which  cases,  never- 
theless, the  surgeon  feels  very  little  doubt  as  to  the  ultimate  cure. 

In  short,  the  causes  which,  according  to  Sir  Astley  Cooper,  deter- 
mine the  extraordinary  fatality  of  these  accidents,  do  not  sufficiently 
differ  from  those  which  operate  in  compound  fractures  to  occasion  so 
great  a  difference  in  results,  and  the  fatality  of  compound  dislocations 

1  Upon  this  point,  see  tlie  very  able  article  entitled  "  Amputations  and  Compound 
Fractures,"  by  John  O.  Stone,  in  the  New  York  Journal  of  Medicine,  vol.  iii.  of 
3d  series,  p.  316,  Nov.  1849. 


748      COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES. 

remains  unexplained ;  or  if  surgical  writers  have  here  and  there  in- 
timated the  true  cause,  they  have  failed  to  give  it  its  proper  place 
and  value. 

I  think  the  cause  of  the  greater  fatality  of  compound  dislocations 
over  compound  fractures  is  to  be  found  in  the  simple  fact  that  dislo- 
cations are  generally  reduced,  and  by  splints  or  other  apparatus  suc- 
cessfully maintained  in  place,  while  compound  fractures,  as  my 
statistical  report  of  cases  has  proven,  are  not  generally  reduced  com- 
pletely, nor  can  they  by  any  means  yet  devised,  except  in  a  few  cases, 
be  maintained  in  place  if  reduced.  Broken  limbs,  whether  simple  or 
compound  in  their  character,  will  in  a  great  majority  of  cases  shorten 
upon  themselves  in  spite  of  the  most  assiduous  and  skilful  attempts 
to  prevent  it.^ 

In  adults  most  bones  break  obliquely,  and  cannot  be  made  to  sup- 
port each  other,  and  even  in  transverse  fractures  the  broken  ends  are 
generally  small  compared  with  the  articular  ends  of  the  same  bones, 
and  afford  a  very  uncertain  and  inadequate  support  for  themselves ; 
not  to  speak  of  the  difficulty  of  once  bringing  their  ends  into  exact 
apposition  where  the  muscles  are  powerful,  or  where  they  lie  imbed- 
ded in  a  large  mass  of  flesh  so  that  they  cannot  be  felt.  While,  on 
the  other  hand,  dislocated  bones,  whether  simple  or  compound,  are 
capable,  when  restored  to  place,  of  supporting  themselves;  or  with 
only  slight  assistance,  their  reduction  may  be  maintained;  it  is  also 
ordinarily  a  work  of  no  great  difficulty  to  reduce  them. 

Herein,  then,  consists  the  most  important  difference  between  these 
two  classes  of  accidents,  which  are  in  other  respects  so  similar.  In 
the  one,  the  very  nature  of  the  injury  prevents  the  complete  reduc- 
tion, and  the  consequent  violent  strain  of  the  muscles,  tendons,  and 
other  soft  tissues;  while  in  the  other,  the  nature  of  the  accident  leaves 
it  in  the  power  of  the  surgeon  to  reduce  the  bones,  and  modern  sur- 
gery has  in  a  great  measure  sanctioned  the  practice  of  maintaining 
them  in  place,  in  defiance  of  the  efforts  of  the  muscles,  and  sometimes, 
no  doubt,  at  the  imminent  hazard  of  the  life  of  the  patient. 

Is  it  not  fair  to  presume  that  tissues  which  have  been  stretched  and 
lacerated,  require  rest  in  order  that  they  may  recover  from  the  eff'ects 
of  their  injuries?  And  if  the  soft  parts  are  really  more  injured  in 
dislocations  than  in  fractures,  does  not  the  indication  for  rest  become, 
for  this  very  reason,  more  imperative  ? 

General'  Inferences. — We  have  come,  then,  to  regard  the  shortening 
of  limbs  after  fractures,  within  certain  limits  and  in  certain  cases,  as 
a  conservative  circumstance  rather  than  as  a  circumstance  which  the 
surgeon  should  in  all  cases  seek  to  prevent. 

There  is  abundant  evidence  that  the  ancients  had  some  knowledge 
of  the  value  of  rest  to  the  muscles,  tendons,  &c.,  in  the  prevention  of 
inflammation  after  compound  dislocations,  since  they  constantly  urge 
the  greater  danger  of  reducing  these  dislocations,  than  of  leaving 
them  unreduced  ;  and  they  do  not  hesitate  to  recommend,  that  in  case 

'  "  Report  on  Deformities  after  Fractures."  Trans.  Am.  Med.  Assoc,  vols,  viii., 
ix.  and  x. 


co:mpouxd  dislocatioxs  of  the  loxg  boxes.    749 

violent  inflammation  supervenes  upon  the  reduction,  the  bone  shall 
immediately  be  again  dislocated.  Galen  speaks  very  explicitly  on 
this  subject,  and  says  that  "the  danger  in  reduction  consists  partly  in 
the  additional  violence  inflicted  on  the  muscles,  and  partly  in  their 
being  then  put  into  a  stretched  state,  whereby  spasms  or  convulsions 
are  brouglit  on,  and  gangrene  as  the  result  of  the  intense  inflamma- 
tion which  ensues ;"  and  Paulus  ^gineta  remarks :  "For  these,  if  re- 
duced, occasion  the  most  imminent  danger,  and  sometimes  death ;  the 
surrounding  nerves  and  muscles  being  inflamed  by  the  extension,"  &c. 

I  have  already  quoted  from  Sir  Astley  Cooper  the  causes  or  rea- 
sons which  he  has  assigned  for  the  fatality  of  compound  dislocations; 
and  the  same  reasons  have  generally  been  assigned  by  those  who  have 
Avritten  since  his  day ;  but  he  has  elsewhere,  when  speaking  of  ex- 
section,  given  place  to  the  very  idea  for  which  we  claim  so  much  pro- 
minence, the  danger  arising  from  a  stretching  of  the  muscles.  Mr. 
Liston,  also,  and  Mr.  Miller,  when  speaking  especially  of  dislocations 
of  the  tibia  at  the  ankle-joint,  refer  to  the  same  source  of  danger. 

Treatment. — Let  us  see  now  the  alternatives  which  surgery  presents 
for  the  treatment  of  these  intractable  accidents. 

1.  Eeduction  of  the  bone. 

2.  Non-reduction. 

3.  Amputation. 

4.  Tenotomy. 

5.  Resection  and  reduction. 

The  questions  for  us  to  consider  are,  first,  by  which  of  these  several 
methods  is  the  life  of  the  patient  rendered  most  secure  ?  and  second, 
where,  of  two  or  more  methods,  all  are  equally  safe,  by  which  will  he 
suffer  the  least  maiming  or  mutilation  ? 

By  Reduction. — We  have  seen  already  how  the  old  surgeons  re- 
garded the  practice  of  reducing  comj)ound  dislocations  of  the  larger 
joints.  It  is  not  difi&cult,  however,  to  find  in  the  records  of  surgery 
numerous  examples  of  successful  terminations  under  this  practice. 

Dr.  White,  of  Hudson,  N.  Y.,  has  reported  a  case  of  this  kind  in 
which  the  dislocation  was  at  the  ankle-joint.^  Pott  says  he  has  seen 
this  practice  occasionally  succeed,^  and  Mr,  Scott  communicated  to 
the  Lancet,  in  March,  1837,  a  case  of  compound  dislocation  of  the 
humerus  successfully  treated  by  reduction.  Sir  Astley  Cooper  also 
records  several  cases  of  compound  dislocations  at  the  lower  end  of  the 
tibia  and  fibula,  successfully  treated  by  reduction. 

A  careful  examination,  however,  of  those  cases  reported  by  Sir 
Astley  as  having  been  reduced  without  resection,  and  which  resulted 
in  cures,  does  not,  in  my  opinion,  leave  much  substantial  evidence  in 
favor  of  the  practice ;  or  perhaps  we  ought  rather  to  say  that  it  leaves 
only  a  qualified  evidence  of  its  propriety  in  certain  cases.  He  has 
mentioned  about  sixteen  of  these  examples,  comprising  dislocations  of 
the  lower  end  of  the  tibia,  or  of  the  tibia  and  fibula,  outwards,  also 
inwards  and  forwards,  all  of  which,  save  one  quoted  from  Mr.  Liston, 

>  White,  Amer.  Journ.  Med.  Sci.,  Nov.  1828,  p.  109. 
2  Pott,  Chirurg.  Works,  vol.  ii.  p.  243. 


750      COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES. 

have  been  reported  to  him  by  other  surgeons,  and  not  one  of 'which 
had  he  ever  seen  himself.  Many  of  the  cases  are  reported  very  loosely, 
evidently  in  reply  to  circular  letters,  and  from  memory,  without  re- 
corded notes,  and  by  unknown,  and  in  some  sense  irresponsible  sur- 
geons. It  is  not  always  said  whether  the  wounds  in  the  soft  parts 
were  made  by  the  protrusion  of  the  bones,  or  by  some  external 
violence ;  yet  this  is  certainly  a  very  material  point  in  determining 
whether  reduction  is  to  be  followed  by  inflammation  or  not.  The 
results,  sometimes  only  attained  after  exposure  to  great  hazards,  are, 
after  all,  often  sufficiently  unfavorable. 

It  will  be  noticed,  also,  that  in  Cases  152  and  153,  the  astragalus 
was  comminuted  and  removed,  either  at  first  or  at  a  later  day;  and 
in  Cases  151,  155,  156,  and  160,  the  tibia,  and  also  probably  the 
fibula,  were  broken,  and  it  does  not  appear  but  that  in  consequence  of 
this  complication  the  limb  became  shortened,  and  the  muscles  were 
thus  put  at  rest,  very  much  as  if  the  bones  had  been  retracted;  and 
in  one  of  the  cases  enumerated  under  161,  the  lower  end  of  the  tibia 
spontaneously  exfoliated.  That  a  comminution  or  that  any  fracture 
of  the  astragalus,  or  of  the  tibia  and  fibula,  should  be  regarded  in  these 
cases  as  rendering  the  accident  less  grave,  can  only  be  comprehended 
by  a  full  appreciation  of  the  value  of  relaxation  of  the  muscles. 

The  few  cases  which  remain  after  this  exclusion  do  indeed  illustrate 
how  nature  and  skill  may  triumph  over  great  difficulties,  but  nothing 
more. 

It  is  possible,  also,  that  some  of  these  examples  of  recovery  after 
reduction  may  admit  of  an  explanation  entirely  consistent  with  our 
own  views  of  the  true  source  of  the  danger  in  these  accidents,  if  in-deed 
they  do  not  tend  actually  to  confirm  our  doctrines.  I  have  myself 
seen  one  example  of  complete  recovery  after  the  reduction  of  a  com- 
pound dislocation  at  the  ankle-joint,  although  resection  was  not  prac- 
tised; but  in  this  case,  all  the  tissues,  or  nearly  all  which  suffered  any 
injury,  were  completely  torn  asunder,  and  therefore  wholly  removed 
fi'om  the  danger  of  which  we  have  spoken.  The  example  to  which 
we  allude  is  the  following  :  On  the  30th  of  Oct.  1858,  John  Bourquard, 
aet.  30,  was  caught  in  the  tow-line  of  a  canal-boat,  causing  a  compound 
dislocation  of  the  right  ankle-joint.  I  found  the  foot,  immediately 
after  the  accident,  thrown  completely  back  against  the  lower  part  of 
the  leg,  the  integuments  in  front  of  the  joint,  as  well  as  all  of  the  ten- 
dons and  ligaments  on  this  side,  being  completely  torn  asunder,  while 
the  tendo-Achillis,  and  the  tendons  behind  both  of  the  malleoli,  with 
the  corresponding  integuments,  were  uninjured.  This  immunity  of 
the  tissues  behind  the  malleoli  was  due  to  the  direction  in  which  the 
foot  was  drawn,  namely,  directly  backwards.  Everything  which  had 
suffered  a  strain  being  thoroughly  severed,  I  did  not  hesitate  to  attempt 
to  save  the  limb  without  resection.  The  reduction  was  accomplished 
very  easily.  The  leg  and  foot  were  placed  in  a  box  filled  with  bran, 
and  cool  water  dressings  were  applied  to  the  portion  which  was  ex- 
posed. On  the  22d  of  November  the  limb  was  removed  from  the 
bran  to  a  pillow,  the  union  being  sufficient  not  to  demand  so  much 


COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES.      751 

lateral  support.  About  the  first  of  March  he  left  the  hospital,  the 
wound  having  closed,  but  the  ankle  remaining  swollen  and  stiff. 

I  have  also  seen  two  cases  in  which  the  foot  has  been  nearly 
severed  from  the  leg  through  the  ankle-joint,  by  means  of  a  "  reaper." 
In  each  case  the  patient  was  standing  with  his  back  to  the  machine, 
and  one  of  the  blades  cut  horizontally  from  side  to  side,  severing 
everything  except  about  three  inches  of  integuments  in  front,  and 
the  extensor  tendons  of  the  toes.  In  the  first  instance,  having  seen 
the  patient,  a  gentleman  nearly  sixty  years  of  age,  within  three  or 
four  hours  of  the  time  of  the  receipt  of  the  injury,  I  found  him  ex- 
ceedingly exhausted  by  the  hemorrhage.  Both  malleoli  were  cut  off 
smoothly,  the  .knife,  having  severed  the  limb  so  exactly  through  the 
joint,  as  to  have  touched  the  cartilage  at  but  one  or  two  points.  Having 
secured  the  bloodvessels,  I  replaced  the  foot,  and  after  a  few  days  of 
attendance  I  left  him  in  the  charge  of  an  excellent  young  surgeon.  Dr. 
Robertson,  of  Lancaster,  N.  Y.,  to  whose  diligence  and  skill  the  patient 
isjao  doubt  mainly  indebted  for  his  recovery.  After  the  lapse  of 
nejn'ly  one  year  he  was  able,  by  the  assistance  of  a  shoe  furnished  with 
lateral  supports,  to  walk  very  well.  In  the  second  case,  which  was 
only  brought  to  my  notice  some  months  after  the  accident  occurred, 
in  consequence  of  a  troublesome  fistula  near  the  ankle-joint,  the  re- 
covery had  been  complete  except  that  a  small  fragment  of  one  of  the 
malleoli  was  necrosed  and  required  removal. 

Dr.  Eli  Hurd,  of  Niagara  Co.,  N.  Y.,  was  equally  fortunate  in  a  case 
of  compound  dislocation  of  the  shoulder-joint.  This  was  in  the  person 
of  G.  T.,  set.  80,  who  was  caught  in  the  gearing  of  a  threshing-machine 
on  the  18th  of  Feb.  1852,  which,  having  drawn  him  in  with  great  force, 
dislocated  the  head  of  the  left  humerus  downwards  through  the  integu- 
ments into  the  axilla.  Reduction  was  accomplished  according  to  the 
method  recommended  by  Nathan  Smith,  by  pulling  from  each  wrist 
at  right  angles  with  the  body,  while  the  operator  himself  seized  the 
naked  head  of  the  humerus  with  his  left  hand,  his  right  resting  upon 
the  top  of  the  shoulder,  and  pushed  it  into  place.  The  time  occupied 
in  the  reduction  was  about  thirty  seconds.  The  forearm  was  then 
suspended  in  a  sling,  and  the  venous  hemorrhage,  occasioned  by  a 
rupture  of  the  subclavian  vein,  was  arrested  by  compression.  The 
tegumentary  wound,  between  three  and  four  inches  in  length,  was 
subsequently  closed  by  sutures,  and  cool  water  dressings  were  applied. 
On  the  fourth  day  the  wound  had  united  by  first  intention,  and  the 
man  was  walking  about  his  room.  In  less  than  a  month  he  was  dis- 
missed cured,  and  in  the  following  harvest  he  was  able  to  cut  his  own 
hay  and  grain,  and  to  use  his  arm  as  before  the  accident,^ 

Miller  and  Hoffman  reduced  successfully  a  compound  dislocation 
of  the  knee,^  and  Galli  has  communicated  a  similar  case  to  Malgaigne.'^ 

Whether  either  of  the  last  three  mentioned  examples  admit  of  the 
same  explanation  as  the  preceding  three,  I  am  unable  to  say,  but 
whether  they  do  or  do  not,  they  are  too  exceptional  in  their  character 

'  Hurd,  Buffalo  Med.  Journ.,  vol.  ix.  p.  119. 

2  Miller  and  Hoffman,  London  Med.  Repos.,  vol.  xxiv.  p.  346. 

2  Galli,  Malgaigne,  op.  cit.,  t.  ii.  p.  958. 


752      COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES. 

to  prejudice  the  argument  materially  which  we  shall  hereafter  make 
in  favor  of  resection. 

Non- Reduction. — On  the  other  hand,  it  will  be  very  difficult  to  find 
an  equal  number  of  cases  of  compound  dislocations,  unreduced,  which 
have  terminated  favorably.  The  fact  is,  no  doubt,  that  at  the  present 
day  very  few  surgeons  would  feel  themselves  justified  in  leaving  a 
bone  out  of  place  unless  they  proceeded  to  amputate.  In  the  Trans- 
actions of  the  New  York  State  Medical  Society  for  1855,  I  have  re- 
ported (Case  16  of  Tibia  and  Fibula,  p.  87)  a  compound  dislocation 
at  the  ankle-joint,  which,  being  unreduced,  terminated  fatally  on  the 
twenty-eighth  day.  This  is  the  only  example  of  a  compound  dislo- 
cation of  a  long  bone,  left  unreduced,  which  has  fallen  under  my 
observation ;  excepting,  of  course,  those  cases  in  which  amputation 
was  immediately  practised. 

The  united  testimony,  however,  of  the  old  surgeons,  who  generally 
neither  amputated  nor  adopted  the  method  of  resection,  but  who  re- 
commended and  practised  non-reduction,  is,  that  it  is  much  more|afe 
to  leave  these  bones  unreduced,  than  to  reduce  them  without  resec- 
tion ;  and  I  see  no  reason  to  doubt  the  correctness  of  their  opinions 
in  this  matter.  But  whether  it  would  be  more  safe  to  leave  such 
limbs  unreduced,  or  having  practised  resection  to  restore  them,  is 
another  question,  in  which  the  advantage  and  comparative  safety  of 
the  latter  practice  are  too  obvious  to  require  explanation  or  defence. 

Amputation. — Says  Pott:  "When  this  accident  (dislocation  of  the 
ankle)  is  accompanied,  as  it  sometimes  is,  with  a  wound  of  the  integu- 
ments of  the  inner  ankle,  and  that  made  by  the  protrusion  of  the  bone, 
it  not  unfrequently  ends  in  a  fatal  gangrene,  unless  prevented  by 
timely  amputation,  though  I  have  several  times  seen  it  do  very  well 
without."  And  Sir  Astley  Cooper,  speaking  of  compound  disloca- 
tions of  the  ankle-joint,  remarks:  "Thirty  years  ago  it  was  the  prac- 
tice to  amputate  limbs  for  this  accident,  and  the  operation  was  then 
thought  absolutely  necessary  for  the  preservation  of  life,  by  some  of 
our  best  surgeons."  Nor  is  it  difficult  to  see  by  what  reasoning  sur- 
geons of  "  thirty  years  ago"  had  fallen  back  upon  this  desperate  remedy. 
Both  reduction  and  non-reduction  having  proven  eminently  hazardous, 
in  the  absence  of  perhaps  both  knowledge  and  experience  in  resec- 
tion, they  finally  adopted  the  alternative  of  amputation,  as  that  which 
after  all  must  give  to  the  patient  the  best  chance  for  life;  and  were 
no  other  alternatives  to  be  presented,  this  would  be  our  choice  in  a 
large  proportion  of  cases. 

It  must  not  be  understood,  however,  that  amputation  is  an  expedient 
wholly  free  from  danger ;  or,  indeed,  that  the  chances  of  the  patient 
are  in  the  average  very  greatly  increased  by  this  practice.  Of  thirteen 
amputations  made  for  compound  dislocations  at  the  ankle-joint,  in  the 
Eoyal  Infirmary  at  Edinburgh,  only  two  resulted  in  the  recovery  of 
the  patients.^  Alluding  to  which,  Mr.  Fergusson  remarks:  "An 
amount  of  mortality  which  may  well  incline  the  surgeon  to  act  upon 
the  doctrine  inculcated  by  Sir  Astley  Cooper"  (to  attempt  to  save 

'  Edinb.  Med.  IMontlily,  Aug.  1844. 


COMPOUND    DISLOCATIOXS    OF    THE    LOXG    BOXES.      753 

the  limb  bj  reduction).  But  Mr.  Fergusson  has  added  a  sentiment 
which  accords  very  closely  with  my  own  experience  and  opinions. 
"I  fear,  however,  that  in  the  attempts  which  have  been  made  to  save 
the  foot  (by  reduction),  the  results  in  all  the  cases  have  not  met  with 
the  same  publicity — that  the  instances  where  amputation  has  been 
afterwards  necessary,  or  where  death  has  been  the  consequence,  have 
not  always  been  recorded  ;  and,  from  what  I  have  myself  seen,  I  would 
caution  the  inexperienced  practitioner  from  being  over-sanguine  in 
anticipating  a  happy  result  in  every  example." 

By  Tenotomy. — As  a  means  of  overcoming  the  resistance  of  the 
muscles,  and  for  the  purpose  especially  of  facilitating  the  reduction, 
tenotomy  has  been  proposed.  First  by  DiefFenbach  in  cases  of  ancient 
unreduced  luxations;  but  Wm.  Hey,  Jr.,  was  the  first  to  make  a  prac- 
tical application  of  this  suggestion  in  a  case  of  compound  dislocation. 
After  cutting  the  tendo-Achillis,  the  ankle  being  dislocated,  the  re- 
duction was  easily  effected,  but  a  strong  tendency  to  displacement 
backwards  remained,  and  he  was  obliged  afterwards  to  cut  the  ten- 
dons of  the  tibialis  posticus  and  flexor  longus  digitorum.^ 

This  method,  based  in  some  degree  upon  a  very  correct  notion  of 
the  principal  sources  of  difficulty,  I  regard  as  totally  impracticable, 
at  least  to  any  useful  or  adequate  extent.  In  order  to  be  efficient,  all 
the  tendons  passing  the  articulations  must  be  cut,  or  nearly  all  of 
them  ;  and  I  doubt  whether  the  judgment  of  any  discreet  surgeon 
will  ever  sanction  such  an  extreme,  I  might  almost  say  such  an  ab- 
surd, measure.  Nor  do  I  think  that  in  the  point  of  view  in  which  we 
are  now  considering  this  subject,  having  reference  only  to  the  ques- 
tion of  danger,  if  the  cutting  of  the  tendons  was  sufficiently  extensive 
to  have  any  real  effect  in  facilitating  the  reduction,  the  practice  would 
be  found  to  have  any  advantage  over  other  methods  known  to  be 
eminently  dangerous. 

By  ResecHon. — Finally,  resection  presents  itself  for  our  considera- 
tion as  the  only  remaining  surgical  expedient. 

We  have  seen  that  most  of  the  early  writers  understood  the  effects 
of  a  constant  strain  upon  the  muscles  in  increasing  the  danger  of 
spasms,  inflammation,  and  death ;  but  in  general  they  have  suggested 
no  remedy  but  non-reduction  or  amputation.  Hippocrates,  however, 
uses  the  following  language,  after  speaking  of  resection  of  protruding 
bones  in  accidental  amputations  or  in  fractures  of  the  fingers:  "Com- 
plete resection  of  bones  at  the  joints,  whether  the  foot,  the  hand,  the 
leg,  the  ankle,  the  forearm,  the  wrist,  for  the  most  part,  are  not  at- 
tended with  danger,  unless  one  be  cut  off"  at  once  by  deliquium  animi, 
or  if  continued  fever  supervene  on  the  fourth  day."  To  which  pas- 
sage the  translator  adds  the  following  note :  "  This  paragraph  on  re- 
section of  the  bones  in  compound  dislocations  and  fractures  contains 
almost  all  the  information  on  the  subject  which  is  to  be  found  in  the 
works  of  ancient  medicine."  Celsus  notices  the  practice  of  resection 
in  compound  dislocations  very  briefly,  as  follows  :  "  Si  nudum  os  emi- 

•  Hey,  Trans,  sf  Proviuc.  Med.  and  Surg.  Assoc.,  vol.  xii.  p.  171,  1844. 


754      COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES. 

net,  impedimentum  semper  futurum  est;  ideo  quod  excedit,  abscin- 
dendum  est." 

Mr.  Hey,  of  Leeds,  was  the  first  of  modern  surgeons  who  called 
especial  attention  to  the  value  of  resection  in  compound  dislocations. 

Sabsequentl}^  Mr.  Parks,  of  Liverpool,  in  an  "Account  of  a  New 
Method  of  treating  Diseases  of  the  Joints  of  the  Knee  and  Elbow," 
advocates  the  practice  of  resection  in  certain  cases  of  diseases  of  these 
joints,  but  especially  in  "  affections  of  the  joints  produced  by  external 
violence." 

Mr.  Leveille,  in  France,  also  following,  as  he  affirms,  the  guidance 
of  Hippocrates,  has  advocated  a  similar  practice. 

Velpeau,  Syme,  Fergusson,  Erichsen,  Miller,  Liston,  Chelius,  Lizars, 
Gibson,  Norris,  under  certain  circumstances,  and  especially  where  the 
bones  cannot  otherwise  be  reduced,  and  where  the  dislocations  occur 
in  certain  joints,  and  especially  the  elbow  and  ankle  joints,  recommend 
resection.  To  which  names  we  may  add  that  of  Sir  Astley  Cooper, 
who  has  considered  the  subject,  as  applied  to  the  ankle  joint,  quite  at 
length,  and  who  says:  "I  have  known  no  case  of  death  when  the  ex- 
tremities of  the  bone"  (tibia,  at  the  ankle)  "have  been  sawed  off, 
although  I  shall  have  occasion  to  mention  some  cases  which  termi- 
nated fatally  when  this  was  not  done." 

Why  resection  should  diminish  the  danger  to  life,  by  placing  at 
rest  the  injured  muscles,  has  been  already  sufficiently  considered  ;  but 
it  seems  not  improbable  that,  if  synovial  membranes  are  actually 
more  susceptible  of  violent  and  dangerous  inflammations  than  the 
other  tissues  about  the  joints,  then  would  this  source  of  danger  be 
removed  just  in  proportion  as  the  synovial  membranes  themselves  are 
removed.  Such,  indeed,  was  the  argument  used  by  Sir  Astley  ;  and 
Mr.  South,  in  a  note  to  Chelius,  when  referring  to  this  fact,  has  made 
the  following  statement : — 

"In  compound  dislocations  of  the  ankle-joint,  with  protrusion  of 
the  shin-bone  through  the  wound,  most  English  surgeons  saw  off  the 
joint  end,  not  merely  to  render  reduction  more  easy,  but  also,  accord- 
ing to  Sir  Astley  Cooper's  opinions,  to  lessen  the  suppurative  process, 
by  diminishing  the  synovial  surface.  This  mode  of  practice  is  cer- 
tainly not  commonly  followed  in  reference  to  other  joints,  and  the 
younger  Cline  was  always  opposed  to  its  being  resorted  to  in  dislo- 
cated ankle." 

The  following  case,  having  occurred  under  my  own  eye,  will  serve 
to  illustrate  the  value  of  the  principle  which  I  have  been  endeavoring 
to  establish: — 

Samuel  Adamson,  of  Buffalo,  set.  24,  was  caught  by  the  cable  of  a 
vessel,  June  17,  1855,  dislocating  the  left  tibia  at  its  lower  end  in- 
wards, and  breaking  the  fibula  two  inches  above  the  ankle.  I  was 
immediately  called,  and  found  the  tibia  protruding  through  the  skin 
about  three  inches.  The  periosteum  was  torn  up,  and  the  cartilagi- 
nous surface  of  the  end  of  the  bone  was  roughened.  His  thigh  was 
also  severely  bruised  and  lacerated,  but  the  bone  was  not  broken. 

Dr.  Boardman  assisting  me,  we  attempted  to  reduce  the  bones,  but 
with  our  hands  we  found  it  impossible  to  do  so.     I  proceeded  imme- 


COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES.      755 

diatelj  to  remove  about  one  inch  and  a  half  of  the  lower  end  of  the 
tibia  with  the  saw.  The  remaining  portion  was  then  brought  easily 
into  place,  and  the  wound  dressed  with  sutures,  adhesive  straps,  band- 
ages, and  light  splints.  On  the  same  day  he  became  an  inmate  of  the 
marine  wards  at  the  Hospital  of  the  Sisters  of  Charity,  and  was  placed 
under  the  care  of  Dr.  Wilcox,  through  whose  politeness  I  was  per- 
mitted to  see  him  frequently. 

The  wound  in  the  leg  healed  kindly,  with  only  a  slight  amount 
of  inflammation  and  suppuration.  Violent  inflammation,  however, 
occurred  in  the  thigh,  followed  by  extensive  suppuration  and  slough- 
ing. This,  in  fact,  proved  to  be  by  far  the  most  serious  injury,  and 
that  which  most  endangered  his  life  and  delayed  his  recovery. 

After  about  two  months,  the  ankle  was  in  such  a  condition  as  to 
require  little  or  no  further  attention.  The  fragments  of  the  fibula  had 
shortened  upon  each  other  and  were  united,  so  that  the  tibia  rested 
upon  the  astragalus.  It  was  nearly  two  months,  however,  before  he 
began  to  walk,  owing  to  the  condition  of  his  thigh. 

Aug.  24,  1856,  fourteen  months  after  the  accident,  Adamson  called 
at  my  office.  He  was  then  employed  again  as  a  sailor  on  board  the 
schooner  Sebastopol,  and  performed  all  the  duties  of  an  ordinary  deck- 
hand. His  leg  is  shortened  one  inch  and  a  quarter;  from  which,  it 
seems,  that  there  has  been  some  deposit  upon  the  end  of  the  bone, 
which  has  compensated  for  one-quarter  of  an  inch  of  that  which  I 
removed.  The  ankle  is  perfect  in  its  form,  being  neither  turned  to  the 
right  nor  to  the  left,  and  he  treads  square  and  firm  upon  the  sole  of 
his  foot.  There  is  considerable  freedom  of  motion,  especially  in  flexion 
and  extension.     Occasionally  it  becomes  a  little  swollen  and  painful. 

In  a  case  of  compound  dislocation  of  the  upper  end  of  the  humerus, 
occurring  also  under  my  own  observation,  and  recorded  in  the  Trans- 
actions of  the  New  York  State  Medical  Society  for  1855  (p.  27,  Case  14), 
in  which  reduction  was  followed  by  death,  I  have  now  much  reason 
to  believe  that  if  I  had  practised  resection  before  the  reduction,  my 
patient's  chances  for  recovery  would  have  been  greatly  increased; 
perhaps  also  the  case  of  compound  dislocation  at  the  wrist-joint  re- 
corded in  the  same  vol.  (p.  68),  in  which,  having  reduced  the  bones, 
I  was  subsequently  compelled  to  amputate,  may  equally  illustrate  the 
hazard  to  which  the  practice  of  reduction  without  resection  must  often 
expose  the  patient. 

The  same  remarks  I  will  venture  to  apply  to  the  case  of  compound 
dislocation  of  the  hip,  of  which  I  have  already  spoken  as  having  oc- 
curred in  the  practice  of  Dr.  Walker,  of  Charlestown,  Mass.  Had  the 
head  of  the  femur  been  resected  before  its  reduction,  I  cannot  doubt 
but  that  the  unfortunate  man's  chance  for  recovery  would  have  been 
very  greatly  improved. 

Thus,  if  we  consider  the  question  of  the  life  of  the  patient  only,  the 
argument  and  the  testimony  seem  to  favor  resection  in  a  great  ma- 
jority of  cases  of  compound  dislocations  occurring  in  large  joints,  and 
in  a  considerable  number  of  cases  of  similar  accidents  in  the  smaller 
joints.  It  is  certainly  more  safe  than  non-reduction  or  reduction 
without  resection,  and  it  is  probably  quite  as  safe  as  amputation  or 
tenotomy. 


756      COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES. 

But  there  is  another  question,  wbicli  is,  in  our  estimation,  secondary 
to  the  one  now  considered,  but  which  is  often  in  the  estimation  of  the 
patient  himself  of  the  first  importance,  namely,  by  which  method  will 
he  suffer  the  least  maiming  or  mutilation? 

This  question  I  do  not  find  it  difficult  to  answer.  Certainly  it  is 
not  by  non-reduction  or  by  amputation;  and,  putting  tenotomy  aside, 
it  is  now  a  question  only  between  reduction  without  resection,  and 
reduction  with  resection.  These  two  methods,  one  of  which  experi- 
ence has  shown  to  be  fraught  with  danger,  and  the  other  of  which 
experience  has  shown  to  be  relatively  safe,  are  now  to  be  compared  in 
a  point  of  view  in  which  their  antagonisms  are  perhaps  less  conspicu- 
ous, yet  sufficiently  marked. 

First,  In  either  case  the  inflammation  consequent  upon  the  injury 
may  be  violent,  and  the  recovery  slow  and  tedious.  The  same  argu- 
ments, however,  which  we  have  applied  to  the  question  of  the  com- 
parative danger  of  the  two  modes,  must  apply  with  nearly  equal  force 
to  this  question  of  maiming ;  since  the  amount  of  maiming  must  olten 
be  governed  by  the  intensity  and  duration  of  the  inflammation,  and 
upon  this  point  the  testimony  has  been  shown  to  be  in  favor  of  re- 
section. 

It  will  be  observed  that  not  only  is  the  danger  of  maiming  rendered 
more  considerable  by  reduction  without  resection,  because  the  inflam- 
mation is  so  much  more  likely  to  extend  to  the  tendons  and  muscles, 
causing  them  to  adhere  to  each  other,  and  to  become  subsequently 
atrophied,  a  condition  from  which  they  often  never  completely  recover, 
but  also  because  the  ligaments  and  capsules  of  the  joints,  with  the 
synovial  surfaces,  are  in  consequence  encroached  upon,  and  the  free- 
dom of  motion  is  ever  afterwards  greatly  restricted,  if  not  completely 
lost.  This  marked  impairment  of  the  functions  of  the  joint  does  not 
always  happen,  but  it  cannot  be  denied  that  it  does  generally.  Indeed, 
it  is  by  no  means  uncommon  for  these  acfeidents  to  be  followed,  after 
ulcerations  of  the  cartilage,  by  copious  bony  deposits  in  and  around 
the  joints. 

How  is  it,  on  the  other  hand,  with  these  joints  after  resection  ?  I 
have  thus  far  heard  of  no  cases  in  which  complete  anchylosis  resulted; 
but  in  all  considerable  freedom  of  motion  has  returned,  and  in  some 
the  restoration  in  this  respect  has  been  nearly  or  quite  as  complete  as 
before  the  accident. 

Says  Dr.  Kerr,  of  Northampton:  "Several  cases  of  compound 
dislocation  of  the  ankle  have  fallen  under  my  care,  and  it  has  been 
uniformly  my  practice  to  take  off  the  lower  extremity  of  the  tibia,  and 
to  lay  the  limb  in  a  state  of  semiflexion  upon  splints ;  by  this  means 
a  great  degree  of  painful  extension,  and  the  consequent  high  degree 
of  inflammation,  are  avoided.  The  splints  I  used  are  excavated  wood, 
and  much  wider  than  those  in  common  use,  with  thick  movable  pads 
stuffed  with  wool.  I  keep  the  parts  constantly  wetted  with  a  solution  of 
liquor  ammonice  acetatis,  without  removing  the  bandage.  In  my  very 
early  life,  upwards  of  sixty  years  ago,  I  saw  many  attempts  to  reduce 
compound  dislocations  without  removing  any  part  of  the  tibia ;  but, 
to  the  best  of  my  recollection,  they  all  ended  unfavorably,  or,  at  least, 


COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES.      757 

in  amputation.  By  the  method  which  I  have  pursued,  as  above  men- 
tioned, I  have  generally  succeeded  in  saving  the  foot,  and  in  preservino- 
a  tolerable  articulation." 

Sir  Astley  Cooper  has  made  a  valuable  experiment  to  determine 
the  condition  of  the  new  joint  under  these  circumstances;  and  the  vast 
number  of  cases  in  which  resection  has  now  been  practised  in  cases  of 
caries  of  the  articulating  surfaces,  and  their  results,  add  still  more 
substantial  proofs  as  to  the  usefulness  of  the  joints  after  such  opera- 
tions. 

"  I  made  an  incision  upon  the  lower  extremity  of  the  tibia,  at  the 
inner  ankle  of  a  dog,  and  cutting  the  inner  portion  of  the  ligament  of 
the  ankle-joint,  I  produced  a  compound  dislocation  of  the  bone  in- 
wards. I  then  sawed  oft"  the  whole  cartilaginous  extremity  of  the 
tibia,  returned  the  bone  upon  the  astragalus,  closed  the  integuments 
by  suture,  and  bandaged  the  limb  to  preserve  the  bone  in  this  situa- 
tion. Considerable  inflammation  and  suppuration  followed  ;  and  in  a 
week  the  bandage  was  removed.  When  the  wound  had  been  for 
several  weeks  perfectly  healed,  I  dissected  the  limb.  The  ligament 
of  the  joint  was  still  defective  at  the  part  at  which  it  had  been  cut. 
From  the  sawn  surface  of  the  tibia  there  grew  a  ligamento-carti- 
laginous  substance,  which  proceeded  to  the  surface  of  the  cartilage  of 
the  astragalus  to  which  it  adhered.  The  cartilage  of  the  astragalus 
appeared  to  be  absorbed  only  in  one  small  part ;  there  was  no  cavity 
between  the  end  of  the  tibia  and  the  cartilaginous  surface  of  the  astra- 
galus. A  free  motion  existed  between  the  tibia  and  astragalus,  which 
was  permitted  by  the  length  and  flexibility  of  the  ligamentous  sub- 
stance above  described,  so  as  to  give  the  advantage  of  a  joint  where 
no  synovial  articulation  or  cavity  was  to  be  found.  This  experiment 
not  only  shows  the  manner  in  which  the  parts  are  restored,  but  also 
the  advantage  of  passive  motion  ;  for  if  the  part  be  frequently  moved, 
the  intervening  substance  becomes  entirely  ligamentous ;  but  if  it  be 
left  perfectly  at  rest  for  a  length  of  time,  ossific  action  proceeds  from 
the  extremity  of  the  tibia  into  the  ligamentous  substance,  and  thus 
produces  an  ossific  anchylosis." 

Second.  Is  it  not  probable,  moreover,  since  the  limb  can  be  retained 
in  place  so  much  more  easily  after  resection,  that  it  will  actually,  in  a 
majority  of  cases,  be  found  to  have  been  retained  in  place  more  per- 
fectly ?  Even  after  simple  dislocations,  especially  in  those  occurring 
at  the  ankle-joint,  great  deformity  and  much  maiming  are  the  not  un- 
frequent  results,  and  that  too  when  all  diligence  and  care  have  been 
employed.  It  has  been  impossible  always  to  maintain  a  perfect  appo- 
sition in  the  articulating  surfaces.  How  much  greater  must  be  this 
difficulty  in  cases  of  compound  dislocations. 

Third.  The  only  argument  which  remains  in  favor  of  reduction 
without  resection  is  the  necessary  shortening  of  the  limb  after  resec- 
tion. But  this  need  seldom  perhaps  to  exceed  three-quarters  of  an 
inch,  and  often  not  more  than  half  an  inch ;  an  amount  of  shortening 
which,  as  I  have  had  occasion  to  prove  when  treating  of  fractures, 
does  not  necessarily  produce  a  halt,  and  which  indeed  is  often  not 
known  to  exist  by  the  patient  himself. 


758  CONGENITAL    DISLOCATIONS. 

Finally.  It  must  cot  be  inferred  that  the  author  intends  to  recom- 
mend resection  as  a  universal  practice  in  cases  of  compound  disloca- 
tions of  the  long  bones.  He  has  only  sought  to  determine  in  a  general 
manner  its  relative  value  as  compared  with  other  modes  of  procedure; 
and  especially  has  it  been  his  intention  to  bring  more  prominently 
into  view  the  importance  of  rest  and  relaxation  to  the  muscles,  as  an 
element  in  the  treatment  most  essential  to  success.  To  declare  its 
special  application  to  cases  would  demand  a  treatise  more  elaborate 
than  it  was  proposed  to  write.  If,  however,  one  were  to  speak  of  the 
individual  bones  only,  there  seems  sufficient  authority  in  the  facts  and 
arguments  already  presented  to  con  elude- that  resection  is  applicable  to 
certain  compound  dislocations  of  the  clavicle,  humerus,  radius,  and  ulna, 
fingers,  femur,  tibia,  fibula,  and  toes;  in  short,  to  a  certain  proportion 
of  all  these  accidents  occurring  in  the  long  bones  of  the  extremities. 

If  an  attempt  is  made  to  save  the  limb  without  resection,  it  is  scarcely 
necessary  to  say  that  the  success  will  depend,  in  a  great  measure,  upon 
the  care,  attention,  and  skill  bestowed  upon  the  treatment.  Cool  or 
tepid  water-dressings,  according  as  the  indications  or  the  sensations  of 
the  patient  seem  to  demand,  are  among  the  most  valuable  remedial 
agents.  The  limb  must  be  maintained  in  a  position  of  rest,  combined 
with  moderate  elevation;  and  the  bran-dressings,  recommended  in 
compound  fractures,  will  be  found  occasionally  useful. 


CHAPTER   XXVI. 

CONGENITAL  DISLOCATIONS. 

§  1.  General  Observations  and  History. 

We  have  omitted,  until  this  moment,  to  speak  of  Congenital  Dislo- 
cations, because,  whatever  theory  of  causation  we  adopt,  dissections 
have  shown  that  they  are  generally,  in  some  sense,  pathologic,  or  are 
accompanied  with  such  essential  modifications  of  the  anatomical  struc- 
tures as  to  separate  them  entirely  from  ordinary  traumatic  luxations, 
which  alone  constitute  the  proper  subjects  of  consideration  in  the  pre- 
sent treatise.  In  relation  to  congenital  dislocations,  we  shall  find  it 
necessary  to  establish  systems  of  etiology,  symptomatology,  prognosis, 
and  treatment,  having  very  few  points  in  common  with  traumatic  dis- 
locations. Exceptions  to  this  rule  will  occur,  in  examples  of  intra- 
uterine traumatic  luxations,  existing  at  birth  without  either  original 
or  accidental  malformations  of  the  articulations,  or  of  the  adjacent 
muscular,  tendinous,  or  ligamentous  structures ;  yet  only  in  sufficient 
numbers  to  warrant  the  intrusion  of  the  subject  in  this  place. 

It  is  probable  that  congenital  displacements  may  occur  in  all  the 
articulations  of  the  skeleton  ;  and  in  most  of  them  their  existence  has 
been  already  established  by  dissections.  Until  within  a  few  years, 
however,  the  attention  of  surgeons  has  been  almost  entirely  directed 
to  congenital  dislocations  of  the  shoulder  and  hip. 


COXGEXITAL    DISLOCATIONS.  759 

Hippocrates,  in  his  treatise  "  De  Articulis,"  speaks  expressly  of  dis- 
locations of  the  hip  occurring  in  the  mother's  womb,  comprising  them 
under  the  same  order  with  the  different  varieties  of  club-foot. 

Avicenna  and  Ambrose  Pare  have  each  mentioned  original  disloca- 
tions of  the  hip ;  but  the  first  to  record  an  example  with  any  degree 
of  accuracy  was  Kerkring;  in  which  case,  death  having  occurred 
during  infancy,  he  was  able  to  verify  his  opinion  by  an  autopsy. 
Chaussier  has  reported,  in  the  Bulletin  de  la  Faculte  et  de  la  Societe  de 
Mtdecine,  An.  1811  and  1812,  the  case  of  an  infant,  upon  which  he 
discovered,  at  birth,  two  dislocations,  one  at  the  scapulo-humeral  arti- 
culation, and  the  other  at  the  coxo-femoral.  In  1788,  Palletta,  of  Milan, 
published,  under  the  title  of  Adversaria  Chirurgica,  a  collection  of 
observations,  in  which,  among  other  things,  he  has  described  certain 
congenital  malformations  of  the  hip-joint;  and  in  1820  he  published 
another  work,  entitled  Exerciiationes  Patholoyicee,  where  he  enters  into 
a  more  Qomplete  exposition  of  the  nature  and  causes  of  these  de- 
formities. 

In  1826,  Dupuytren  read,  before  the  Academy  of  Sciences,  a  memoir 
upon  the  lameness  produced  by  the  original  displacement  of  the 
femur;  and  in  the  Lemons  Orales,  published  in  the  collections  of  the 
Sydenham  Societ}-,  may  be  found  a  full  record  of  the  views  and  obser- 
vations of  this  distinguished  surgeon. 

Tlie  writings  of  Dupuytren  seem,  more  than  anything  previously 
written,  to  have  directed  the  attention  of  surgeons  and  pathologists  to 
this  interesting  subject,  and  to  have  given  a  new  impulse  to  investi- 
gation. 

From  this  time  various  treatises  have  been  written  by  eminent  sur- 
geons, many  of  which  are  characterized  by  profound  thought,  careful 
investigation,  and  practical  experiment. 

Among  those  who  have  furnished  us  lately  with  elaborate  treatises, 
or  with  more  precise  practical  information  upon  this  subject,  the  fol- 
lowing names  deserve  to  be  especially  mentioned:  Breschet,'  Caillard- 
Biliioni^re,-  Lehoux,^  Sandiforte,^  Duval  and  Lafond,  Humbert  and 
Jacquier,  Bouvier,^  Sedillot,^  Gerdy,  Poliniere,  Wrolik,^  Gudrin,^  Pa- 
rise,'-'  Pravaz,^"  Carnochan,"  and  Kobert  Smith.'^ 

1  Brescbet,  Repertoire  d'Anatomie  et  de  Physiologie. 

2  Caillard-Billioniere,  These  Inaiigurale,  1838. 

3  Lelioux,  These  Inaugurale,  1834,  Paris. 

^  Saudiforte,  Thesis,  sustained  before  tlie  Faculty  of  Med.  of  Leyden. 

5  Duval  and  Lafond,  Humbert  and  Jacquier,  Bouvier.     See  Pravaz. 

^  Sedillot,  Journ.  de  Connais.  Med.-Chirurg.,  1838. 

7  Gerdy,  Polinere,  "Wrolik.     See  Pravaz. 

^  Gueriu,  Recherches  sur  les  Luxations  Congenitales ;  par  Jules  Guerin,  Paris, 
1841. 

3  Parise,  Archiv.  Gen.  de  Med.,  1842. 

•°  Pravaz,  Traite  Theorique  et  Pratique  des  Luxations  Congenitales  du  Femur, 
suivi  d'un  Appendice  sur  la  Prophylaxie  des  Luxations  Spontanees ;  par  Ch.  G. 
Pravaz,  Lyons,  1847. 

•1  Carnochan,  A  Treatise  on  the  Etiology,  Pathology,  and  Treatment  of  Con- 
genital Dislocations  of  the  Head  of  the  Femur  ;  by  John  Murray  Carnochan,  New- 
York,  1850. 

'2  R.  Smith,  A  Treatise  on  Fractures  in  the  Vicinity  of  Joints,  and  on  Certain 
Accidental  and  Congenital  Dislocations ;  Dublin,  1854. 


760 


CONGENITAL    DISLOCATIONS. 


§  2.  Etiology. 

Hippocrates  says  that  the  bones  of  the  extremities  may  be  disar- 
ticulated during  intra-uterine  life  by  falls  or  blows,  or  by  injuries  of 
any  kind,  inflicted  directly  upon  the  abdomen  of  the  mother. 

Ambrose  Pare,  while  admitting  the  efficiency  of  the  several  causes 
named  by  Hippocrates,  believed  also  that  the  contractions  of  the 
womb,  and  violence  employed  by  the  accoucheur,  were  occasionally 
adequate  to  the  production  of  the  same  results.  He  taught,  moreover, 
that  the  position  of  the  foetus  itself  might  favor  the  displacement; 
and  that,  in  some  instances,  an  articular  abscess,  insufficient  depth  of 
the  socket,  with  a  laxity  of  the  ligaments,  were  competent  to  determine 
the  expulsion  of  the  head  of  the  femur  from  its  natural  position. 

Sedillot  regards  a  softening  and  relaxation  of  the  ligaments  as  the 
most  frequent  cause. 

Parise  and  Malgaigne  are  disposed  to  attribute  a  majority  of  these 
cases  to  hydrarthrosis,  or  water  in  the  joints.  Says  Malgaigne  :  "  For 
myself,  after  having  long  meditated  upon  this  subject,  I  have  come  to 
think  that  inflammation  of  the  joints  enjoys  a  grand  role,  both  in 
coxo-femoral  dislocations  and  in  many  others,  and  even  also  in  various 
congenital  malformations  generally  ascribed  to  arrest  of  development." 
This  writer  admits,  however,  that  it  will  not  do  to  generalize  too  much 
in  this  matter,  and  that  the  etiology  of  congenital  luxations  is  probably 
as  complex  as  that  of  luxations  after  birth. 

Chaussier  seems  to  have  regarded  muscular  contraction,  or  the 
occurrence  of  an  intra-uterine  convulsion,  as  the  cause  of  the  example 
of  congenital  dislocation  of  both  humerus  and  femur  seen  and  recorded 
by  him.  Since  whom  Guerin  has  greatly  extended  the  application 
of  this  doctrine,  having  embraced  in  the  same  etiologic  formula  all 
or  nearly  all  congenital  dislocations.  Gudrin  ascribes  to  muscular 
contraction  in  one  form  or  another,  and  to  corresponding  muscular 
paralysis,  not  only  dislocations  of  the  femur  and  other  long  bones, 
but  also  club-foot,  torticollis,  and  various  other  deviations  of  the  spine. 
He  affirms,  moreover,  that  he  has  established  incontestably  the  depend- 
ence of  this  abnormal  state  of  the  muscular  system  upon  the  absence 
or  disappearance  more  or  less  complete  of  corresponding  portions  of 
the  central  nervous  systems. 

Breschet  and  Delpech  maintained  similar  views,  especially  in  rela- 
tion to  the  dependence  of  the  several  varieties  of  club-foot  upon  some 
morbid  condition  of  the  cerebro-spinal  axis.  While  Carnochan  re- 
marks as  follows :  "  It  appears  most  in  accordance  with  science  to 
refer  the  muscular  spasmodic  retraction,  upon  which  congenital  dis- 
locations of  the  head  of  the  femur  from  the  cotyloid  cavity  depend, 
to  a  perverted  condition  of  the  excito-motor  apparatus  of  the  medulla 
spinalis,  and  more  especially  of  that  portion  of  it  which  is  in  direct 
relation  with  the  reflex-motor  nervous  fibres,  distributed  to  the  pelvi- 
femoral  muscles  surrounding,  and  in  connection  with,  the  ilio-femoral 
articulation." 

Palletta  ascribes  these  deformities  solely  to  an  original  defect  of  the 
germ;  and  Dupuytren  also  declares  that,  in  the  case  of  a  congenital 


•  CONGENITAL    DISLOCATIONS    OF    INFERIOR    MAXILLA.      761 

dislocation  of  the  hip,  the  causes  are  coeval  with  the  earliest  organiza- 
tion of  the  parts,  and  that  the  displacement  is  due  rather  to  a  defect 
in  the  depth  or  completeness  of  the  acetabulum,  than  to  accident  or 
disease. 

Breschet  and  Delpech,  both  of  whom,  as  we  have  already  stated, 
refer  them  to  some  morbid  condition  of  the  cerebro-spinal  axis,  ima- 
gine that  in  consequence  of  this  morbid  condition  of  the  nervous 
centres,  there  exists  an  arrest  of  development  in  the  bones,  muscles, 
ligaments,  sockets,  and,  in  short,  through  all  the  apparatus  of  the  joint 
which  is  the  seat  of  the  deformity. 

If  we  proceed  to  analyze  these  various  opinions,  we  shall  find  that 
they  are  so  far  susceptible  of  classification,  as  that  they  may  be 
arranged  under  the  three  following  divisions: — 

First,  the  physiological  doctrines ;  according  to  which  congenital 
dislocations  are  due  to  an  original  defect  in  the  germ,  or  to  an  arrest 
of  development. 

Second,  the  pathologic  doctrines;  which  refer  them  to  some  sup- 
posed-lesion of  the  nervous  centres,  to  contraction  or  paralysis  of  the 
muscles,  to  a  laxity  of  the  ligaments,  to  hydrarthrosis,  or  to  some  other 
diseased  condition  of  the  articulating  apparatus. 

Third,  the  mechanical  doctrines ;  which  recognize  no  intra-uterine 
dislocations  except  those  which  are  strictly  traumatic.  The  causes 
being  understood  to  be  the  peculiar  position  of  the  fcetus  in  utero, 
violent  contractions  or  the  constant  pressure  of  the  walls  of  the  uterus, 
falls  and  blows  upon  the  abdomen,  and  unskilful  manipulation  of  the 
child  in  delivery. 

After  a  full  and  careful  consideration  of  this  subject,  we  are  pre- 
pared to  admit  the  occasional  agency  of  all  the  causes  enumerated, 
and  the  probable  concurrence  of  two  or  more  in  many  instances ;  nor 
do  we  see  the  propriety  of  rejecting,  as  Malgaigne  has  done,  all  that 
large  class  of  malformations,  which  seem  to  depend  upon  an  arrest  of 
development,  or  those  which  appear  to  be  due  mainly  or  solely  to 
intra-uterine  paralysis,  of  both  of  which  many  examples  have  been 
reported. 

§  3.  Congenital  Dislocations  of  the  Inferior  Maxilla. 

Malgaigne  affirms  that ''  we  know  of  no  congenital  dislocation  of  the 
jaw,"  and  that  we  are  "not  to  take  seriously  the  pretended  luxation 
observed  by  Guerin  upon  a  derencdphalous  infant."  The  example 
recorded  by  Eobert  Smith  he  rejects  also,  declaring  that  he  does  "  not 
comprehend  how  one  can  see  in  it  a  luxation." 

For  myself,  I  know  of  no  reason  why  we  should  not  take  "seriously" 
the  case  mentioned  by  Guerin,  since,  so  far  as  appears  in  his  very  brief 
report  of  the  same,  it  might  have  been  a  true  luxation.  The  specimen 
was  before  the  academy,  and  if  Malgaigne,  from  a  personal  examina- 
tion, has  become  satisfied  that  a  dislocation  did  not  exist,  he  ought  to 
have  so  informed  us.  But  since  he  does  not  speak  of  having  made  it 
the  subject  of  especial  examination,  we  shall  feel  compelled  to  accept 
of  it  as  reported  by  Guerin. 

4y 


762  CONGENITAL    DISLOCATIONS. 

As  to  the  objection  offered  to  Mr.  Smith's  case,  namely,  that  "aside 
of  the  complete  absence  of  its  history,  the  subject  did  not  present  the 
characteristic  signs  of  luxation,  and  the  dissection  discovered  neither 
maxillary  condyle  nor  glenoid  cavity,"  we  must  reply,  the  dissection 
seems  to  us  to  have  furnished  such  evidence  that  the  deformity  was 
cono-enital  as  to  render  its  history  unnecessary  ;  the  signs  were  charac- 
teristic, not  indeed  of  a  traumatic  luxation,  but  of  a  congenital  disloca- 
tion, such  as  may  be  supposed  to  have  been  the  result  of  an  arrest  of 
development,  or  of  an  original  aberration  of  the  germ. 

The  following  is  a  summary  of  the  very  complete  account  of  this 
case  given  by  Eobert  Smith. 

On  the  fifth  of  May,  1840,  Edward  Lacy,  set.  38,  an  idiot  from  in- 
fancy, died  at  the  Hardwick  Hospital,  in  consequence  of  gangrene  of 
the  lungs.  While  making  the  autopsy,  a  singular  deformity  of  the 
face  was  discovered.  The  right  and  left  sides  seemed  as  though  they 
did  not  belong  to  the  same  individual,  the  left  being  in  every  respect 
more  fully  developed.  Upon  removing  the  integuments,  the  muscles 
of  the  right  side  were  found  to  be  much  smaller  than  those  of  the  left, 
and  especially  the  masseter.  These  latter  having  been  removed  also, 
the  condition  of  the  right  temporo-maxillary  articulation  was  carefully 
studied. 

When  the  mouth  was  closed,  the  external  lateral  ligament,  instead 
of  being  directed  backwards,  was  seen  descending  obliquely  forwards, 
to  be  attached  to  a  very  imperfectly  developed  condyle  situated  at 
least  one-quarter  of  an  inch  in  front  of  its  natural  position.  There 
was  neither  an  inter-articular  cartilage  nor  cartilage  of  incrustation, 
the  joint  surfaces  being  invested  by  a  thick  periosteum  alone  ;  nor  was 
there  any  distinct  capsular  ligament. 

Nearly  the  whole  of  the  right  side  of  the  inferior  maxilla  was 
smaller  than  the  left.  The  condyle  was  short  and  curved,  being 
directed  nearly  horizontally  inwards,  and  resembling  much  more  the 
coracoid  process  than  the  condyle  of  the  inferior  maxilla.  The  coro- 
noid  process  was  very  small  and  thin,  and  the  sigmoid  notch  could 
scarcely  be  said  to  exist. 

The  articular  eminence  of  the  temporal  bone  was  absent,  there  being 
in  its  place  nearly  a  flat  surface  destitute  of  cartilage;  which  surface 
presented  upon  its  inner  side  a  shallow  and  semicircular  sulcus  where 
the  hook-like  condyle  of  the  lower  jaw  had  played. 

The  malar,  superior  maxillary,  and  sphenoid  bones  of  the  right  side 
had  also  sufi'ered  corresponding  changes  of  form  and  relative  size. 

The  motions  permitted  in  the  lower  jaw  were  more  extensive  than 
those  which  it  enjoys  in  its  normal  condition,  that  is,  upon  the  right 
side  the  ramus  could  be  moved  very  freely  forwards  and  backwards, 
while  upon  the  left,  the  condyle  underwent  a  species  of  rotation  upon 
its  axis.  During  life  the  patient  was  observed  to  be  constantly  per- 
forming this  motion,  and  the  right  side  of  the  face  was  continually 
affected  with  spasmodic  twitches.  When  the  mouth  was  closed,  the 
front  teeth  of  the  upper  jaw  projected  beyond  those  of  the  lower,  and 
when  opened  the  deformity  was  in  all  respects  greatly  increased.* 

'  Robert  Smith,  op.  cit.,  p.  283. 


CO]S"GENITAL    DISLOCATIONS    OF    INFERIOR    MAXILLA.      763 

Mr.  Smith  takes  tliis  occasion  also  to  express  his  dissent  from  the 
views  maintained  by  Eibes,  namely,  that  the  formation  of  the  glenoid 
cavity  is  consequent  upon  the  growth  of  the  condyle,  and  that,  were 
this  process  not  formed,  there  would  not  exist  either  a  glenoid  cavity 
or  an  articular  eminence.  It  is  true  that  neither  the  glenoid  cavity 
nor  the  articular  eminence  is  found  in  the  foetus.  Until  the  seventh 
month  of  intra-uterine  life  there  exists  at  this  point  of  the  temporal 
bone  only  a  plane  surface,  and  the  glenoid  cavity  with  its  correspond- 
ing eminence  is  developed  in  proportion  to  the  growth  and  develop- 
ment of  the  condyle.  But  Mr.  Smith  justly  observes  that  although 
the  development  of  the  condyle  does  precede  that  of  the  glenoid 
cavity,  "it  by  no  means  follows  that  the  formation  of  the  latter  is  due 
to  the  pressure  of  the  former."  The  cavity,  or  rather  the  transverse 
eminence  in  front  of  the  plane  surface,  does  not  exist  in  foetal  life, 
because,  owing  to  the  peculiar  form  of  the  inferior  maxilla  at  this 
period,  its  existence  is  not  necessary.  The  vertical  portion  of  the  jaw 
(vertical  only  in  the  adult)  is  in  the  foetus  nearly  in  the  same  line  with 
the  axis  of  the  shaft,  and  consequently  when  the  mouth  is  opened  by 
the  action  of  the  muscles,  the  condyles  are  pressed  upwards  and  back- 
wards instead  of  upwards  and  forwards,  as  in  the  adult.  A  displace- 
ment forwards  cannot  therefore  very  well  occur ;  and  the  protection 
of  the  articular  eminences  is  not  required.  As  age  advances  the 
angles  of  the  jaw  increase,  the  portions  upon  which  the  condyles  rest 
become  more  vertical,  and  finally  a  displacement  forwards  would  occur 
whenever  the  mouth  was  well  opened  if  the  articular  eminences  were 
not  present  to  afford  a  sufi&cient  protection  in  front. 

In  the  case  of  Lacy  the  foetal  condition  of  the  bones  upon  one  side 
remained  during  life,  there  being  neither  cavity  nor  eminence,  and 
the  condyle  itself  being  only  imperfectly  developed ;  but  the  angle  of 
the  jaw  had  assumed  the  form  which  belongs  to  the  adult,  and  the 
ascending  ramus  was  vertical,  consequently  the  condyle  became  some- 
what displaced  forwards. 

Chronic  rheumatic  arthritis  is  occasionally  found  in  the  temporo- 
maxillary  articulation  of  old  persons ;  and  it  may  be  important  to 
distinguish  it  from  congenital  luxation,  with  which,  owing  to  the  ab- 
sorption of  the  articular  eminence,  and  the  consequent  displacement 
of  the  condyle,  it  might  possibly  be  confounded. 

Says  Mr.  Smith:  "In  a  majority  of  instances,  this  remarkable  dis- 
ease attacks  those  of  advanced  age,  and  is  symmetrical;  but  occasion- 
ally it  occurs  during  the  period  of  adult  life.  In  the  latter  case  it  is 
generally  more  rapid  in  its  progress,  is  accompanied  by  greater  pain, 
and  is  more  liable  to  implicate  the  neck  of  the  condyle,  and  the  ramus 
of  the  jaw." 

When  the  condyle  is  implicated  it  becomes  enlarged,  and  can  be 
felt  beneath  the  zygoma,  in  front  of  the  meatus  externus.  The  lym- 
phatic glands  of  this  region  are  sometimes  enlarged,  and  the  progress 
of  the  malady  is  attended  with  a  constant  but  not  generally  severe 
pain. 

The  deformity  of  the  face  varies  according  as  one  or  both  articula- 
tions are  affected.    When  the  malady  is  confined  to  one  joint,  the  chin 


764-  CONGENITAL    DISLOCATIONS. 

is  thrown  slightly  forwards,  but  chiefly  to  the  opposite  side;  and  when 
both  are  implicated,  the  chin  is  simply  advanced  so  that  the  teeth  pro- 
ject beyond  those  of  the  upper  jaw. 

As  the  disease  progresses,  the  glenoid  cavity  enlarges  by  absorp- 
tion, and  at  length  a  considerable  portion  or  the  whole  of  the  articular 
eminence  disappears  and  the  jaw  becomes  gradually  displaced  through 
the  action  of  the  ex:ternal  pterygoids.  The  disease  does  not  extend 
in  the  temporal  bone  beyond  the  articulating  surface  of  the  glenoid 
cavity.  The  condyle  assumes  a  variety  of  forms,  sometimes  being 
greatly  enlarged  in  all  its  diameters,  while  its  upper  surface  may  be 
flattened,  or  conical.  The  inter-articular  cartilage  disappears;  but 
Mr.  Smith  has  never  yet  found  any  foreign  bodies  in  the  joint,  and  in 
only  one  instance  have  the  surfaces  been  polished  or  eburnated  as  we 
often  see  in  examples  of  chronic  rheumatic  arthritis  occurring  in  the 
hip,  knee,  and  other  joints. 

The  following  is  an  excellent  summary  of  the  diagnostic  marks 
between  congenital,  accidental,  and  rheumatic  dislocations,  given  by 
this  writer : — 

"1.  In  the  congenital  luxation,  the  mouth  can  be  freely  opened  and 
closed ;  in  chronic  rheumatism  these  motions  can  be  performed,  but 
not  without  uneasiness  to  the  patient,  an  uneasiness  which  sometimes 
amounts  to  severe  pain  ;  in  luxations  from  accident,  the  mouth  cannot 
be  closed. 

"  2.  An  involuntary  flow  of  saliva  accompanies  the  accidental  luxa- 
tion alone,  although  in  some  cases  of  chronic  rheumatism  there  is  an 
increased  secretion  of  that  fluid. 

"  3.  In  congenital  luxation,  the  teeth  of  the  upper  jaw  project  be- 
yond those  of  the  lower ;  the  reverse  is  observed  in  accidental  luxa- 
tion and  in  chronic  rheumatism. 

"  4.  In  congenital  luxation  there  is  no  fulness  in  the  cheek,  such  as 
the  coronoid  process  produces  in  cases  of  accidental  luxation,  and  the 
condyle  is  not  enlarged,  as  in  some  instances  of  chronic  rheumatic 
arthritis."^ 

§  4.  Congenital  Dislocations  op  the  Spine. 

Says  Gu^rin,  of  the  subluxation  occipito-atloidean  there  are  two 
varieties :  "  First.  Backwards,  consisting  in  an  exaggerated  flexion  of 
the  head  upon  the  front  of  the  neck  and  chest,  with  a  commencement 
of  sliding  backwards  of  the  occipital  condyles  upon  the  articular 
facets  of  the  atlas.  Here  are  two  examples  in  foetal  enenc^phalous 
monsters.  Second.  Forwards  Those  who  follow  my  consultations 
can  recollect  having  seen  last  year  an  infant,  about  two  or  three 
months  old,  who  offered  a  remarkable  example.  The  head  was  ex- 
actly applied  against  the  posterior  part  of  the  neck,  and  upper  part 
of  the  back.  There  was  probably  a  sliding  of  the  condyles  forwards, 
with  elongation  of  the  anterior  ligaments."^ 

The  existence  of  the  first  of  these  varieties  has  since  been  denied 

'  R.  Smith,  op.cit.,  p.  292.  2  Gu^rin,  op.  cit.,  1841,  p.  29. 


CONGENITAL    DISLOCATIONS    OF    THE    STEENUM.        765 

by  Guerin  himself;^  and  it  will  be  noticed  that  he  only  speaks  of  the 
second  as  o. probable  subluxation  forwards.  Neither  of  them  can  there- 
fore be  regarded  as  established. 

Gudrin  further  remarks  that  he  has  observed  subluxations  in  the 
other  regions  of  the  spinal  column  many  times :  and  he  showed  to  the 
Academy  a  foetus  in  which  the  spine  presented,  besides  the  occipito- 
atloidean  displacement,  a  series  of  angular  flexions  in  the  antero-pos- 
terior  direction,  with  sliding  of  the  articular  surfaces. 

In  attempting  to  appreciate  the  value  of  Guerin's  observations  upon 
this  point,  it  must  be  remembered  that  he  regards  all  cases  of  congeni- 
tal torticollis,  and  other  deviations  of  the  spine,  as  examples  of  sub- 
luxation ;  and,  in  some  sense,  we  think  the  theory  of  this  distinguished 
surgeon  may  be  regarded  as  correct.  The  amount  of  articular  dis- 
placement between  each  of  the  adjacent  vertebra)  may  be  very  incon- 
siderable in  any  such  case,  yet,  however  trivial,  if  it  exceeds  the  limits 
of  natural  motion,  it  may  properly  enough  be  regarded  as  the  com- 
mencement of  a  luxation. 

§  5.  Congenital  Dislocations  op  the  Pelvic  Bones. 

Bassius  speaks  of  a  diastasis  or  separation  of  the  sacro-iliac  sym- 
physis, observed  by  him  in  newly-born  children,  and  in  infants;  but, 
according  to  Malgaigne,  his  account  of  these  cases  is  not  such  as  to 
warrant  any  conclusions  as  to  the  true  nature  of  the  displacements. 

Congenital  exstrophy  of  the  bladder  is  accompanied  always  with  a 
deficiency  of  the  central  and  upper  portions  of  the  pubic  bones,  the 
result  manifestly  of  an  arrest  of  development ;  but  these  cases,  of 
which  I  have  seen  several  examples,  are  not  properly  examples,  of 
congenital  dislocations,  but  only  of  diastases,  the  separated  portions  re- 
maining in  their  normal  position  with  reference  to  each  other,  except 
that  they  are  not  prolonged  sufficiently  to  meet  in  the  median  line. 

Gudrin  declares,  however,  that  he  has  seen  congenital  displacement, 
or  overriding  of  the  iliac  bone  upon  the  sacrum,  accompanied  with 
coxo-femoral  dislocation  and  curvature  of  the  spine.  The  same  writer 
mentions  an  example,  in  a  foetal  monster,  of  diastasis  of  the  pubic 
bones,  and  of  the  sacro-iliac  symphysis,  accompanied  with  a  turning 
out  of  the  pubes  upon  the  external  face  of  the  ischium.^ 

§  6.  Congenital  Dislocations  of  the  Sternum. 

Seger  alone  has  reported  one  example  of  luxation  of  the  xiphoid 
cartilage  from  the  sternum. 

A  woman  in  her  fifth  month  of  pregnancy  fell  and  dislocated  her 
shoulder.  Jij^t  four  months  after  this  she  was  brought  to  bed  with 
an  infant,  well  formed,  except  that,  soon  after  it  was  born,  the  ensiform 
cartilage  was  observed  to  be  remarkably  movable,  especially  when  the 
child  hiccoughed,  to  which  it  was  very  subject.  The  cartilage  was 
separated  from  the  sternum  by  the  breadth  of  the  little  finger.     No 

'  Ibid.,  op.  cit.,  p.  33.  2  ibid.,  Gaz.  Med.,  1851,  p.  227. 


766  CONGENITAL    DISLOCATIONS. 

treatment  was  employed;  tlie  cartilage  gradually  became  restored  to 
its  place,  and  in  about  one  year  it  was  firmly  united  to  the  sternum.^ 

§  1.  Congenital  Dislocations  of  the  Clavicle. 

Malgaigne  says  that  a  congenital  dislocation  at  the  sterno-clavicular 
articulation  has  never  been  observed;  but  Guerin  declares  that  he  has 
established  the  existence  of  three  varieties,  namely : — 

1.  A  luxation  of  the  sternal  end  of  the  clavicle  inwards  and  for- 
wards; this  extremity  of  the  clavicle  lying  in  front  of  the  sternal 
fourchette.  In  illustration  of  which  he  presented  to  the  Academy  a 
plaster  cast  of  a  girl  eight  years  old,  in  whom  the  displacement  existed 
upon  both  sides. 

2.  Inwards  and  upwards.  Observed  by  him  in  a  girl  eight  years 
old ;  but  which  displacement  took  place  only  when  the  arm  was 
moved,  and  through  the  contraction  of  the  sterno-cleido-mastoideus 
muscle. 

3.  Backwards.  Of  which  he  presented  two  examples  in  the  cor- 
responding sides  of  a  foetal  monster. 

I  believe  I  have  already  referred  to  Fergusson's  case  of  dislocation 
of  the  sternal  end  of  the  clavicle  forwards,  which  occurred  during 
birth.  The  end  rested  in  front  of  the  sternum,  and  could  be  pushed 
into  its  place  with  great  ease ;  but  when  left  alone  it  immediately 
slipped  out  again.  Nothing  was  done,  a  new  joint  formed,  and  the 
child  afterwards  possessed  as  much  power  in  the  one  arm  as  in  the 
other.^ 

Guerin  says  that  he  has  seen  a  dislocation  upwards  and  outwards  at 
the  acromial  end  of  the  clavicle  in  a  foetus  of  three  months. 

In  regard  to  the  treatment  of  either  of  these  displacements  of  the 
clavicle,  we  need  only  remark  that  a  reduction  ought  to  be  attempted ; 
and,  if  practicable,  without  much  confinement  of  the  little  patient,  it 
should  be  maintained  until  the  bones  have  become  fixed  in  their 
natural  positions.  It  is  quite  probable  that  this  can  never  be  accom- 
plished, at  least  perfectly ;  but  it  will  nevertheless  be  proper  always 
to  make  the  attempt. 

§  8.  Congenital  Dislocations  of  the  Shoulder.      (Ujyper  End  of  the 

Humerus.) 

Guerin  affirms  that  he  has  established  the  existence  of  three  varie- 
ties of  scapulo-humeral  dislocations,  namely  : — 

1.  Dislocations  of  the  head  of  the  humerus  downwards;  of  which 
variety  he  presented  to  the  Academy  a  plaster  cast  taken  from  a  boy 
ten  years  old.  The  displacement  existed  in  both  arms,  but  much 
more  pronounced  in  the  right  than  in  the  left  arm.  It  was  due  wholly 
to  paralysis  of  the  muscles  about  the  joint,  and  to  elongation  of  the 
capsule. 

'  Seger,  Ephem.  Nat.  Curios.,  1677,  from  Malg.,  op.  cit.,  p.  410. 
2  Fergusson,  System  of  Surg.,  4tli  Amer.  ed.,  1853,  p.  203. 


CONGENITAL    DISLOCATIONS    OF    THE    SHOULDER.      767 

2.  Downwards  and  inwards ;  complete  upon  one  side  and  incom- 
plete upon  the  other,  in  the  same  person.  The  head  of  each  humerus 
was  applied  against  the  ribs,  and  the  arms  maintained  in  an  abduc- 
tion almost  horizontal,  under  the  influence  of  the  retraction  of  the 
deltoid  muscles.  "The  same  case,''  Gudrin  remarks,  "has  been  con- 
firmed by  Roux." 

3.  Subluxation  upwards  and  outwards :  seen  on  both  sides  in  a 
foetal  monster,  which  was  offered  to  the  Academy  for  examination ; 
and  in  one  arm  of  a  young  man  fifteen  years  old,  of  which  Guerin 
presented  a  plaster  cast.  "  It  is  characterized  by  a  sliding  of  the  head 
of  the  humerus  in  the  direction  indicated ;  this  sliding  being  favored 
by  a  corresponding  displacement  of  the  coracoid  and  acromion  pro- 
cesses."^ 

Malgaigne,  who  regards  "  all  luxations  in  consequence  of  paralysis 
as  essentially  posterior  to  birth,"  will  not  admit  the  first  example 
mentioned  by  Guerin ;  but,  as  we  stated  before,  the  objections  made 
by  Malgaigne  have  failed  to  convince  us  of  the  propriety  of  rejecting 
all  of  this  class  of  reported  examples.  Of  the  second  case,  mentioned 
by  Guerin  as  having  been  confirmed  by  Roux,  Malgaigne  declares 
that  he  has  consulted  Roux  upon  this  matter,  and  that  he  affirms  that 
"he  has  never  seen  a  congenital  luxation  of  the  shoulder." 

Robert  Smith  has  met  with  but  two  of  the  forms  of  congenital 
luxation  of  the  humerus  described  by  Guerin,  namely,  that  in  which 
the  head  of  the  humerus  is  displaced  forwards,  and  that  in  which  it 
is  displaced  backwards.  Of  the  first  variety  be  has  seen  several  ex- 
amples. 

The  first  was  in  the  person  of  Alexander  Steele,  aet.  29,  who  pre- 
sented both  a  dislocation  of  the  head  of  the  humerus  under  the  cora- 
coid process  of  the  left  scapula,  and  pes  equinus  in  the  foot  of  the  left 
leg.  The  muscles  of  the  arm  and  shoulder  upon  that  side  were  feeble 
and  greatly  atrophied.  The  humerus  waS  shortened ;  its  head  being 
of  the  natural  size  and  form,  but  when  the  arm  hung  by  the  side  it 
dropped  so  far  from  its  socket  as  to  permit  the  thumb  to  be  placed 
between  the  head  and  the  acromion  process.  By  pressing  the  hume- 
rus forwards  the  finger  could  be  placed  in  the  outer  part  of  the  glenoid 
cavity ;  and,  although  the  head  could  be  moved  about  thus  freely,  it 
seemed  naturally  to  occupy  only  the  anterior  half  of  the  glenoid 
fossa. 

Robert  Smith's  second  example  of  subcoracoid  congenital  luxation 
was  presented  in  the  person  of  Mr.  H.,  set.  20,  the  condition  of  whose 
left  shoulder  resembled  almost  precisely  that  of  Mr.  Steele.  "  The 
deformity  had  existed  from  his  birth,  but  became  much  more  obvious 
and  striking  as  he  increased  in  age  and  stature." 

In  the  third  example  the  child  had  attained  nearly  the  age  of  one 
year  before  the  condition  of  the  limb  attracted  attention,  which  was 
then  excited,  not  by  the  deformity  of  the  shoulder,  but  by  the  atro- 
phied condition  of  the  muscles  of  the  arm.  The  child  had  never 
complained  of  pain  about  the  joint,  nor  had  he  ever  met  with  any  ac- 

'  Guerin,  op.  cit.,  p.  30. 


768  CONGENITAL    DISLOCATIONS. 

cident.  No  doubt  this  also  was  an  example  of  paralysis,  and  it  is  not 
improbable  that  it  was  congenital,  but  the  evidence  upon  this  point  is 
not  very  conclusive.  When  seen  by  Mr.  Smith,  he  was  nine  years 
old,  the  shoulder  and  arm  presenting  the  same  appearance  as  in  the 
other  cases  mentioned. 

The  fourth  was  also  subcoracoid  and  symmetrical,  the  same  defor- 
mity existing  in  both  shoulders.  This  was  in  the  person  of  a  female, 
set.  21,  who  had  been  for  many  years  a  patient  in  a  lunatic  asylum, 
and  who  died  of  chronic  inflammation  of  the  meninges  of  the  brain. 

Mr.  Smith,  who  himself  made  the  autopsy,  first  noticed  the  condi- 
tion of  the  left  shoulder.  The  muscles  were  atrophied ;  the  head  of 
the  humerus  could  be  felt  lying  under  the  coracoid  process ;  the  elbow 
projected  from  the  side,  but  could  be  readily  brought  into  contact 
with  it.  The  right  shoulder  presented  the  same  appearance,  but  the 
deformity  was  somewhat  less,  and  the  head  of  the  humerus  was  not 
so  directly  underneath  the  coracoid  process. 

From  the  external  appearances  presented  by  the  two  shoulders,  Mr. 
Smith  did  not  doubt  that  these  deviations  from  the  natural  state  of 
the  parts  were  not  the  result  of  violence. 

Proceeding  to  remove  the  soft  parts  upon  the  left  side,  scarcely  any 
trace  was  found  of  a  glenoid  cavity  in  its  natural  situation,  but  im- 
mediately underneath  the  coracoid  process,  upon  the  costal  surface  of 
the  scapula,  was  formed  an  oblong  socket  completely  surrounded  by 
a  capsular  ligament,  which  ligament  included  also  that  small  portion 
of  the  original  socket  which  remained.  The  head  of  the  humerus 
was  changed  in  form,  being  oval,  and  fitted,  in  some  measure,  to  both 
the  old  and  new  sockets,  upon  which  it  seemed  to  rest  alternately. 

Upon  the  right  side,  although  the  condition  of  the  bones  was  some- 
what different,  the  characteristic  features  of  the  deformity  were  similar. 

Malgaigne,  who  quotes  Mr.  Smith  as  saying  that  these  dislocations 
must  have  been  congenital,  and  for  no  other  reason  than  because  they 
were  symmetrical,  has  scarcely  done  this  author  justice.  Says  Mr. 
Smith:  "The  position  of  the  glenoid  cavity,  the  remarkable  form  of 
the  head  of  the  humerus,  the  presence  of  a  perfect  glenoid  ligament, 
the  absence  of  any  trace  of  disease,  and  the  existence  of  the  defor- 
mity upon  each  side,  all  indicate  the  original  nature  of  the  malforma- 
tion." 

The  only  example  of  backward  luxation  seen  by  Mr.  Smith  was 
also  symmetrical,  and  seems  to  be  equally  well  authenticated.  This 
was  in  the  person  of  a  woman  named  Doyle,  set.  42,  a  lunatic  also, 
who  died  Feb.  8,  1839,  in  Dublin.  She  had  been  a  patient  in  the 
lunatic  asylum  fifteen  years,  and  was  subject  to  severe  epileptic  con- 
vulsions, which  ultimately  proved  fatal. 

Mr.  Smith  made  the  autopsy  on  the  day  following  her  death.  The 
convolutions  of  the  brain  were  small  and  atrophied,  as  is  frequently 
observed  in  idiots. 

The  two  shoulders  resembled  each  other  so  perfectly,  both  in  ex- 
ternal appearance  and  in  their  anatomy,  that  Mr.  Smith  has  only 
found  it  necessary  to  describe  particularly  the  condition  of  one. 

The  coracoid  process  was  remarkably  prominent,  but  the  acromion 


CONGENITAL    DISLOCATIONS    OF    THE    SHOULDER.      769 

was  not  so  prominent  as  in  accidental  dislocations  of  the  shoulder. 
The  head  of  the  humerus  could  be  seen  and  felt  distinctly  moving 
with  the  shaft,  upon  the  dorsal  surface  of  the  scapula.  On  removing 
the  integuments,  muscles,  &c.,  no  trace  of  a  glenoid  cavity  was  found 
in  its  natural  situation ;  but  upon  the  external  surface  of  the  neck  of 
the  scapula  was  a  well-formed  socket,  which  received  the  head  of  the 
humerus.  This  socket  was  covered  with  a  cartilage  of  incrustation, 
and  surrounded  by  a  perfect  capsule.  The  tendon  of  the  biceps  arose 
from  the  top  and  internal  margin  of  the  socket.  The  form  of  the 
acromion  process  was  changed ;  the  capsule  smaller  than  natural ;  the 
head  of  the  humerus  irregularly  oval,  its  anterior  half  alone  being 
in  contact  with  the  glenoid  cavity  ;  the  great  tubercle  natural,  but  the 
lesser  was  elongated  and  curved,  forming  a  process  of  an  inch  in 
length,  around  the  base  of  which  the  tendon  of  the  biceps  muscles 
played.^ 

Gaillard  relates  the  case  of  a  female  child,  upon  whom  the  left  arm 
was  discovered  to  be  deformed  a  few  days  after  birth,  and  the  elbow 
separated  from  the  side.  Later,  the  arm  was  found  to  be  nearly  im- 
movable, and  only  at  the  end  of  four  years  was  the  dislocation  recog- 
nized; but  no  attempt  at  reduction  was  then  made.  When  sixteen 
years  old,  she  was  seen  by  Gaillard,  who  found  the  head  of  the  hume- 
rus in  the  infra-spinous  fossa.  The  scapula,  clavicle,  and  arm  were 
preternatu rally  small ;  the  forearm,  although  well  developed,  could 
not  be  completely  extended  nor  supinated. 

Despite  these  unfavorable  circumstances,  Gaillard  determined  to 
make  an  attempt  to  accomplish  the  reduction.  Four  times  in  the  space 
of  eight  days  he  submitted  the  arms  to  extension  made  at  right  angles 
with  the  body,  by  means  of  sixteen-pound  weights,  the  extension  being 
continued  from  twenty  to  twenty-five  minutes,  and  occasionally  his 
own  exertions  being  added  to  the  weights.  On  the  fourth  attempt, 
the  head  of  the  bone  was  drawn  gradually  forwards,  and  by  a  rotatory 
motion  it  was  finally  made  to  slip  into  its  socket;  but  it  became  im- 
mediately displaced.  The  next  day  Gaillard  reduced  it  anew,  and 
retained  it  ia  place  one  hour.  Six  days  later  it  was  again  reduced, 
and,  by  the  aid  of  bandages,  permanently  retained  in  place.  The 
slight  pain  and  swelling  which  followed  soon  disappeared  ;  and  by  the 
aid  of  careful  exercise,  at  the  end  of  two  years  the  arm  had  increased 
in  length,  and  the  patient  could  use  the  arm  and  hand  so  much  better 
than  before,  as  to  encourage  a  hope  that  the  recovery  would  be  com- 
plete.^ 

Aristide  Rodrigue,  of  Hollidaysburg,  Penn.,  in  a  letter  to  the  editor 
of  the  American  Journal  of  Medical  Sciences,  gives  the  following  brief 
account  of  a  case  of  intra-uterine  dislocation  of  the  shoulder,  compli- 
cated with  a  fracture  of  the  forearm. 

"The  woman,  when  about  four  months  gone  with  child,  fell  on  her 
left  side,  striking  a  board,  and  felt  herself  much  hurt  at  the  time:  at 
the  full  period  she  was  delivered  of  a  full-grown  large  boy  with  the 

•  Robert  Smith,  op.  cit. 

2  Gaillard,  Mem.  de  P Acad.  de.  Med.,  1841,  from  Malg.,  p.  569. 


770  CONGENITAL    DISLOCATIONS. 

following  deformity :  dislocation  of  the  humerus  into  the  axilla ;  frac- 
ture of  both  bones  of  the  forearm  of  left  side,  lower  third.  Dislocation 
could  not  be  reduced;  union  of  the  bones  of  the  forearm  by  ossific 
matter  complete ;  bones  passing  each  other,  and  hand  at  an  angle  of 
about  40°;  the  child  did  well  otherwise;  now,  four  years  old,  strong 
and  healthy  ;  humerus  has  grown  nearly  apace  with  the  other ;  forearm 
has  not,  and  remains  short  and  deformed  as  in  birth ;  the  hand  is  of 
the  same  size  with  that  of  the  sound  side."^ 

§  9.  Congenital  Dislocations  op  the  Radius  and  Ulna  Backwards. 

It  is  not  uncommon  to  meet  with  examples  of  a  slight  subluxation 
backwards  of  these  bones  in  feeble  and  newly-born  infants;  which 
condition  is  probably  due  to  a  relaxation  and  elongation  of  the  cap- 
sule. It  is  characterized  by  a  preternatural  mobility  of  the  joint,  and 
especially  by  the  circumstance  that  the  limb  is  capable  of  abnormal 
extension,  or  flexion  backwards,  as  it  is  sometimes  called.  Gudrin  has 
seen  this  condition  more  advanced,  the  bones  of  the  forearm  having 
actually  overlapped  somewhat  upon  the  lower  end  of  the  humerus,  so 
that  the  articular  surface  of  this  latter  presented  itself  in  the  fold  of 
the  elbow.  This  was  especially  observed  in  a  girl  of  fourteen  and  a 
boy  of  thirteen  years,  and  also  in  the  two  arms  of  a  foetal  monster.^ 

Chaussier  relates  that  a  young  woman,  at  the  commencement  of  the 
ninth  month  of  pregnancy,  perceived  suddenly  movements  of  the  foetus 
so  violent  that  she  almost  lost  her  consciousness.  These  movements 
were  repeated  three  times  in  the  space  of  six  minutes,  after  which 
everything  returned  to  its  natural  order,  and  the  accouchement  took 
place  naturally  and  at  the  usual  term.  The  infant  was  pale  and  feeble, 
and  presented  a  complete  backward  luxation  of  the  radius  and  ulna.^ 

§  10.  Congenital  Dislocations  of  the  Head  of  the  Radius. 

Examples  of  this,  luxation  have  been  reported  by  Dupuytren,  Cru- 
veilhier,  Sandiforte,  Adams,  Dubois,  Verneuil,  Deville,  Robert  Smith, 
and  Guerin,  most  of  which  were  in  the  direction  backwards,  some 
outwards,  but  only  one  of  them  forwards;  some  were  double,  the  same 
deformity  being  presented  in  both  arms,  and  others  were  single.  In 
a  few  examples  the  dislocations  were  complicated  with  a  consolidation 
of  the  radius  to  the  ulna,  and  in  others  with  a  deficiency  of  the  ulna 
or  with  some  deformity  indicating  its  congenital  origin. 

Of  the  symmetrical  or  double  dislocation  backwards  Dupuytren 
furnishes  the  following  example,  presented  to  him  in  1830,  by  M. 
Loir :  "  The  abnormal  position  which  the  head  of  either  radius  had 
assumed  was  at  the  back  part  of  the  lower  extremity  of  the  humerus, 
beyond  which  it  extended  for  the  space  of  at  least  an  inch.  This 
disposition  of  parts  was  absolutely  identical  on  the  two  sides,  and  had 
all  the  characters  of  a  congenital  aS'ection."" 

1  Rodrigiie,  loc.  cit.,  Jan.  1854,  p.  272.  2  Guerin,  op.  cit.,  p.  31. 

2  Cliaussier,  from  Malgaigne,  op.  cit.,  t.  ii.  p.  268. 
^  Dupuytren,  Injuries  and  Dis.  of  Bones,  p.  117. 


CONGENITAL    DISLOCATIONS    OF    THE    WRIST.  771 

In  Jan.  1866,  John  Fitzmorris,  aet.  19,  was  admitted  to  the  Bellevue 
Hospital,  laboring  under  a  general  scrofulous  cachexy,  in  whose 
person  I  found  a  congenital  dislocation  of  the  heads  of  both  radii,  out- 
wards. The  luxations  are  complete.  The  ulnas  are  in  place  and  of 
natural  form,  but  their  articulations  at  the  wrist  are  loose.  The  same 
remark  applies  to  all  the  other  joints  in  the  body.  The  power  of  pro- 
nation and  supination  is  unimpaired,  as  well,  also,  as  the  power  of 
flexion  and  extension. 

In  the  example  of  outward  luxation,  mentioned  by  Deville,  there 
was  an  almost  complete  absence  of  the  ulna,  the  head  of  the  radius 
mounting  upwards  more  than  three  centimetres  above  the  level  of  the 
articulation.' 

Guerin,  who  has  described  the  only  example  of  a  forward  luxation, 
says  it  was  observed  by  him  in  a  girl  of  seven  years,  and  that  it  was 
symmetrical.  The  two  radii  lay  in  front  of  the  humeri,  near  the  coro- 
nary fossettes.^ 

§  11.  Congenital  Dislocations  of  the  Wrist. 

Guerin  thinks  he  has  seen  three  forms  of  congenital  luxation  of  the 
wrist.  First,  a  dislocation  forwards  characterized  by  a  sliding  of  the 
wrist  before  the  bones  of  the  forearm,  and  by  the  projection  posteriorly 
of  the  lower  ends  of  the  radius  and  ulna;  seen  in  an  infant  of  six 
months,  and  in  two  adults.  Second,  backwards  and  upwards;  seen 
in  a  child  of  six  years,  and  accompanied  with  an  incomplete  paralysis 
of  all  the  muscles  of  the  forearm  and  hand.  Third,  backwards  and 
outwards;  in  a  girl  of  fourteen  years,  accompanied  with  incomplete 
paralysis.^ 

Guerin  has  also  seen  three  examples  of  dislocation  outwards  in 
foetal  monsters,  and  one  of  dislocation  inwards,  as  the  result  of  arrest 
of  development. 

Robert  Smith  believes  that  the  case  of  simple  dislocation  of  the 
wrist  or  of  the  carpus  forwards,  mentioned  by  Cruveilhier  in  his 
Anatomie  Pathohgique,  was  an  example  of  congenital  luxation ;  and  he 
relates  two  other  cases  equally  remarkable  which  came  under  his  own 
observation.  One  was  in  the  person  of  Deborah  O'Neil,  a  lunatic  and 
epileptic,  who  died  when  thirty-six  years  old.  Both  upper  extremities 
were  deformed  from  birth;  the  right  presenting  an  example  of  dislo- 
cation of  the  carpus  forwards,  and  the  left  of  dislocation  of  the  carpus 
backwards.  The  dissection  showed  that  there  had  been  an  arrest  of 
development,  especially  in  the  bones  of  the  forearm  and  carpus.  The 
second  was  in  the  person  of  a  young  woman  who  died  of  phthisis  in 
the  Richmond  Hospital;  the  right  wrist  presenting  an  example  of 
congenital  dislocation  of  the  carpus  forwards  from  arrest  of  develop- 
ment also.^ 

Marrigues  describes  a  very  singular  congenital  displacement  which 
he  found  upon  a  newly-born  infant.    The  radius  and  ulna  were  widely 

'  Deville,  Bulletins  de  la  Soc.  Auat.,  1849,  p.  153. 

2  Guerin,  op.  cit.,  p.  31.  "  Ibid.,  p.  717. 

«  R.  Smith,  op.  cit.,  pp.  238,  2ol. 


772  CONGENITAL    DISLOCATIONS. 

separated  below,  and  in  the  interspace  was  lodged  the  whole  of  the 
first  range  of  the  carpal  bones ;  the  hand  being  strongly  turned  in- 
wards.^ 

§  12.  Congenital  Dislocations  op  the  Fingers. 

Chaussier  found  in  a  foetus  the  last  three  fingers  of  the  left  hand 
dislocated  at  the  metacarpo-phalangeal  articulation.  The  thighs,  knees, 
and  feet  were  also  dislocated.^ 

A.  Bdrard  speaks  of  an  incurvation  backwards  of  the  last  two  pha- 
langes of  the  fingers  as  having  been  occasionally  seen  in  newly-born 
children  of  the  female  sex;  and  Malgaigne  adds  that  he  has  himself 
seen  a  woman  who  had,  from  birth,  all  the  phalangettes  carried  back- 
wards to  an  angle  of  135°,  leaving  the  heads  of  the  phalanges  project- 
ing forward  under  the  skin.^ 

Eobert  has  seen,  in  a  girl  six  years  old,  a  congenital  lateral  luxation 
of  the  jjhalangeUe  of  the  index  finger,  which  was  inclined  outwards  at 
an  obtuse  angle.  The  external  condyle  of  the  lower  extremity  of  the 
proximal  phalanx  was  slightly  atrophied,  and  the  internal  presented  a 
corresponding  projection.  Robert  cut  the  internal  lateral  ligament  by 
a  subcutaneous  incision,  but  without  any  favorable  result."* 

§  13.  Congenital  Dislocations  op  the  Hip. 

Dupuytren  thought  that  double  dislocations  of  the  hip-joint,  as 
congenital  accidents,  were  more  common  than  single  dislocations,  but 
in  the  experience  of  Pravaz  the  rule  has  been  reversed,  he  having  met 
with  but  four  double  dislocations  in  a  total  of  nineteen. 

Congenital  dislocations  of  the  femur  have  been  noticed  much  oftener 
in  females  than  in  males.  Of  forty-five  examples  mentioned  by  Du- 
puytren and  Pravaz,  only  seven  or  eight  were  males. 

They  may  be  complete  or  incomplete.  Of  the  complete  luxations, 
four  varieties  have  been  noticed. 

Upwards  and  backwards,  upon  the  dorsum  ilii.  This  variety  is  by 
far  the  most  common. 

Upwards  and  forwards;  the  head  of  the  femur  resting  upon  the 
eminentia  ilio-pectinea. 

Downwards  and  forwards  into  the  foramen  thyroideum;  of  which 
variety  Chaussier  alone  mentions  one  example ;  but  Delpech  found  in 
an  infant,  born  paralytic,  the  head  of  the  femur  lodged  habitually  near 
the  foramen  thyroideum. 

Directly  upwards;  seen  by  Gudrin,  Pravaz,  and  others;  the  head 
of  the  femur  being  placed  immediately  without  the  anterior  inferior 
spinous  process  of  the  ilium. 

Guerin  has  observed,  moreover,  a  single  variety  of  subluxation; 
characterized  by  the  incomplete  displacement  of  the  head  of  the  femur 

'  Marrigues,  Malgaigne,  from  Journ.  de  M6d.,  1775,  t.  ii.  p.  31. 
2  Chaussier,  Malgaigne,  op.  cit.,  t.  ii,  p.  751. 

*  Berard,  Malgaigne,  op.  cit.,  p.  773. 

*  Robert,  from  Malg.,  op.  cit.,  p.  773. 


CONGENITAL    DISLOCATIONS    OF    THE    HIP.  773 

in  the  direction  upwards  and  backwards,  so  that  it  rested  upon  the 
edge  of  the  cotyloid  cavity:  "observed  often  in  newly-born  children, 
and  with  those  in  whom  the  muscular  dislocations  are  effected  sponta- 
neously after  birth." 

Through  the  courtesy  of  Dr.  Davis,  of  this  city,  I  was  permitted,  in 
March,  1865,  to  see  a  child,  the  daughter  of  a  gentleman  residing  in 
Victor,  Monroe  Co.,  N.  Y.,  who  was  born  in  1860,  with  dislocation  of 
both  knees  and  both  hip^joints.  The  legs  at  the  time  of  birth  were 
doubled  forward  upon  the  thighs,  the  heads  of  the  tibias  resting  upon 
the  front  of  the  femurs,  one  inch  above  the  condyles,  the  thighs  being 
at  right  angles  with  the  body  and  the  feet  touching  the  abdomen.  The 
knees  were  drawn  closely  together.  The  dislocation  of  the  heads  of 
the  femurs  was  not  at  this  time  recognized.  By  constant  pressure  Dr. 
J.  B.  Palmer  had  succeeded,  at  the  end  of  one  year,  in  restoring  the 
leg  to  position,  the  thighs  remaining  flexed ;  but  when  two  years 
old  she  began  to  walk  with  her  body  bent  forwards.  The  displace- 
ment of  the  hip-bones  was  then  first  discovered.  When  four  years 
old  the  sartorius  and  tensor  vaginae  femoris  were  severed,  but  with 
very  little  benefit.  At  the  time  of  my  examination  she  was  five  years 
old.  The  thighs  were  still  flexed  and  adducted  ;  by  pressure  upon  the 
knees  the  femurs  could  be  slid  upwards  and  backwards  upon  the  ilium 
one  inch :  on  rotating  the  femurs  the  trochanters  were  observed  to 
move  upon  a  very  short  radius,  indicating  the  entire  absence  of  head 
and  neck.     She  walked  with  the  gait  peculiar  to  these  conditions. 

Both  Delpech  and  Guerin  have  called  attention  to  two  varieties  of 
what  the  latter  terms  pseudo-luxations:  of  which  the  first  simulates 
a  dislocation  upwards  and  backwards,  and  the  second  a  dislocation 
downwards  and  forwards.  In  these  examples,  the  extreme  adduction 
or  abduction  of  the  thighs  might  lead  to  a  belief  that  the  bones  were 
dislocated,  when  in  fact  the  abnormal  position  of  the  limbs  is  due 
only  to  muscular  contraction,  without  actual  articular  displacement. 

in  the  remarks  which  follow  we  shall  have  special  reference  to  that 
form  of  congenital  dislocations  of  the  femur  in  which  the  head  of  the 
bone  rests  upon  the  dorsum  ilii,  as  being  that  which  will  be  presented 
in  a  vast  majority  of  cases,  and  which,  characterized  by  the  same 
general  phenomena,  may  be  regarded  as  typical  of  all  the  others. 
Symptomatology. — First.  When  the  dislocation  is  double. 
In  these  examples  the  deformity  is  often  found  to  be  symmetrical ; 
the  opposite  limbs  being  precisely  the  same  length,  and  in  the  same 
relative  positions;  a  circumstance  which,  when  it  exists,  may  render 
the  diagnosis  more  difficult,  or  may  cause  it  to  be  for  a  long  time 
entirely  overlooked.  It  is  in  such  cases  especially  that  the  deformity 
is  not  usually  discovered  until  the  child  begins  to  walk. 

The  first  circumstance  which  would  naturally  arrest  our  attention 
if  the  person  who  is  the  subject  of  this  double  dislocation  is  stripped 
and  placed  erect  before  us,  is  the  great  apparent  length  of  the  arms 
and  of  the  body  in  comparison  with  the  lower  extremities.  We  may 
next  observe  that  the  great  trochanters  are  carried  upwards  and  back- 
wards, so  as  to  make  a  remarkable  projection  in  this  direction;  the 
lumbar  portion  of  the  spinal  column  is  thrown  very  much  forwards 


774  CONGENITAL    DISLOCATIONS. 

and  the  dorsal  portion  backwards.  The  thighs  incline  inwards,  so  as 
almost  to  cross  each  other ;  the  whole  of  the  lower  extremities  are 
imperfectly  developed  and  feeble ;  the  toes  are  generally  pointed  di- 
rectly forwards,  or  they  may  be  noticed  to  turn  inwards. 

When  the  person  stands,  and  his  limbs  are  not  in  motion,  the  heel 
is  usually  brought  down  fairly  to  the  floor;  but  in  walking,  and 
especially  in  the  attempt  to  run,  he  touches  only  the  balls  and  toes  of 
his  feet.  "  When  they  are  about  to  walk,"  says  Pravaz,  "  we  see  them 
lift  themselves  upon  the  points  of  the  feet,  to  incline  the  superior  part 
of  the  trunk  toward  the  member  which  is  about  to  support  the  weight 
of  the  body,  and  to  lift  the  other  from  the  ground  with  an  effort,  in 
order  to  carry  it  forwards.  At  this  moment  one  of  the  trochanters, 
that  which  corresponds  to  the  column  of  sustentation,  appears  to 
approach  the  iliac  crest  more  nearly  than  when  the  patient  is  standing 
upon  his  two  feet."  In  consequence  of  which  mobility  of  the  thigh- 
bones, the  patient  assumes  a  peculiar  waddling  gait,  which  is  not  only 
ungraceful,  but  exceedingly  fatiguing. 

The  difficulty  of  progression  is,  however,  very  variable  in  different 
persons.  Sometimes  the  patient  requires  no  aid  whatever,  and  at 
other  times  he  cannot  walk  without  assistance.  Generally  it  increases 
with  age.  It  is  especially  deserving  of  notice  that  in  rapid  progression 
the  mobility  of  the  heads  of  the  femurs  is  appreciably  less  than  in 
slow  progression,  which  is  explained  by  the  more  constant  and  vigor- 
ous contraction  of  the  muscles  about  the  joint,  when  the  motions  of 
the  limb  are  rapid. 

In  the  recumbent  posture,  the  thighs  may  be  drawn  down  easily  to 
almost  their  natural  positions.  The  only  exception  to  this  rule,  accord- 
ing to  Carnochan,  "  is  when  the  head  of  the  femur  has  escaped  from 
the  natural  capsule  in  which  it  was  originally  inclosed,  and  a  new 
socket  has  been  formed  upon  the  dorsum  of  the  ilium." 

Abduction  is  performed  with  difficulty;  adduction  and  rotation, 
especially  inv/ards,  being  less  restricted. 

Second.  When  the  dislocation  is  only  upon  one  side. 

In  these  cases  the  symptoms  are  essentially  the  same  as  in  the  double 
dislocation  ;  with  only  such  slight  differences  and  peculiarities  as  would 
naturally  suggest  themselves  to  the  surgeon,  and  which  will  not,  there- 
fore, demand  from  us  a  special  consideration. 

Pathology. — The  head  of  the  femur  is  sometimes  merely  changed  in 
form  and  consistence,  the  neck  also  undergoing  corresponding  altera- 
tions in  its  size,  form,  direction,  &c. ;  at  other  times  the  head  is  absent 
altogether,  and  with  it  a  considerable  portion  or  the  whole  of  the  neck 
has  disappeared. 

The  pelvic  bones  are  usually  more  or  less  deformed.  The  acetabu- 
lum may  be  entirely  deficient,  or  it  may  present  itself  as  an  irregular 
bony  protuberance,  without  cartilage,  fibro-cartilage,  or  ligaments. 
Sometimes  it  exists  as  an  oval  or  triangular  cavity,  which  is  expanded 
at  its  superior  and  posterior  margin  into  a  distinct  fossa,  where  the 
head  of  the  femur,  descending  from  the  dorsum  ilii,  occasionally  rests. 
A  new  cavity  is  formed  usually  upon  the  side  of  the  pelvis,  which  is 
shallow  and  without  an  elevated  margin,  or  it  may  be  deeper,  and  more 


CONGENITAL    DISLOCATIONS    OF    THE    HIP.  775 

complete  in  its  construction,  by  the  addition  of  an  osseous  border.  In 
either  case,  the  new  socket  is  often  lined  with  a  true  periosteum  and 
synovial  membrane;  but  not  unfrequentlj  it  is  unprotected  by  any 
soft  tissue,  the  surface  being  hard  and  polished  like  ivory. 

The  head  of  the  femur,  having  escaped  from  its  original  capsule, 
through  a  button-like  opening,  rests  in  this  socket  constantly.  In  still 
other  examples  the  head  of  the  femur  remains  within  its  capsule,  and 
may  be  observed  to  play  backwards  and  forwards  between  the  two 
sockets ;  or  the  head  and  neck  being  absorbed,  and  the  capsule  remain- 
ing entire,  the  latter  is  converted  into  a  long  narrow  sac,  somewhat 
contracted  in  its  centre,  or  finally  into  a  firm  ligamentous  cord,  which 
being  attached  to  the  stunted  upper  extremity  of  the  femur,  limits  its 
motions  in  the  direction  of  the  crest  of  the  ilium.  In  this  case  no  new 
socket  is  formed. 

A  portion  of  the  pelvi-femoral  muscles  are  contracted,  in  conse- 
quence of  an  approximation  of  their  points  of  origin  and  insertion,  and 
remaining  in  a  state  of  comparative,  if  not  absolute,  inertia,  they 
become  atrophied,  or  pass  into  a  condition  of  fatty  degeneration,  while 
other  muscles,  in  consequence  of  the  increased  labor  which  they  have 
to  perform,  become  hypertrophied,  or  degenerate  into  a  fibrous  tissue. 

Treatment. — Says  Dupuytren  :  "  Of  what  possible  utility  can  it  be  to 
practise  extension  of  the  lower  extremities  in  these  cases,  even  sup- 
posing the  limbs  could  be  thus  brought  to  their  natural  length  ?  Is 
it  not  evident  that  the  head  of  the  femur,  finding  no  cavity  fitted  to 
receive  and  hold  it,  would,  when  abandoned  to  itself,  resume  its  former 
abnormal  position  ?  There  is  something  more  rational  and  feasible 
in  adopting  a  palliative  course  of  treatment.  When  we  call  to  mind 
the  natural  proneness  which  the  heads  of  thigh-bones  have  to  ascend 
to  the  external  iliac  fossae,  and  that  this  tendency  is  partly  due  to  the 
superincumbent  weight  of  the  body,  and  in  part  to  muscular  action,  a 
just  conception  may  be  formed  of  the  indications  on  which  the  employ- 
ment of  palliative  remedies  should  be  founded.  The  object  should  be 
to  relieve  the  lower  limbs  of  the  superincumbent  weight  on  the  one 
hand,  and  on  the  other  to  moderate  the  muscular  action.  Both  of 
these  indications  are  in  part  fulfilled  by  repose;  and  the  attitude  most 
conducive  to  this  effect  is  the  sitting  posture,  in  which  the  weight  of 
the  upper  part  of  the  body  is  not  transmitted  to  the  lower  extremities, 
but  is  centred  in  the  tuberosities  of  the  ischia.  Therefore,  laboring 
persons  afflicted  with  this  infirmity  should  be  recommended  to  adopt 
a  sedentary  occupation,  as  a  calling  which  requires  much  standing  and 
walking  about  would  dangerously  aggravate  their  deformity.  Yet 
one  would  scarcely  be  willing  to  condemn  such  individuals  to  per- 
petual repose;  and  to  avoid  this  it  is  necessary  to  discover  some  means 
lor  diminishing  the  inconveniences  which  attend  the  upright  posture, 
the  act  of  walking  and  other  exercises.  Experience  has  taught  me 
hitherto  but  two  methods  of  obtaining  this  important  object:  the  first 
consists  in  the  daily  employment  of  a  perfectly  cold  bath,  in  which 
all  the  body  should  be  immersed  for  the  space  of  three  or  four  min- 
utes, the  head  being  protected  by  an  oiled-silk  cap;  the  water  ma}^  be 
fresh  or  salt ;  and  the  only  precautions  necessary  to  take  are  to  avoid 


776  CONGENITAL    DISLOCATIONS. 

bathing  when  the  body  is  in  a  state  of  perspiration,  or  when  the  cata- 
meuial  discharge  is  present.  These  baths  have  a  local,  as  well  as 
general,  tonic  effect.  The  second  method  consists  in  the  constant  use, 
at  least  during  the  day,  of  a  belt,  which  embraces  the  pelvis,  fitting 
closely  over  the  great  trochanters,  and  keeping  them  at  a  constant 
height,  so  as  to  bind  the  parts  together,  and  prevent  that  continual 
unsteadiness  of  the  body  which  results  from  the  loose  connections  of 
the  heads  of  the  thigh-bones.  For  the  proper  fulfilment  of  these  in- 
dications, certain  precautions  are  necessary  in  the  construction  of  this 
cincture ;  in  the  first  place,  it  should  occupy  the  narrow  interval  be- 
tween the  crest  of  the  ilium  and  great  trochanters,  completely  filling 
this  space,  and  therefore  being  about  three  or  four  fingers'  breadth, 
according  to  the  age  and  size  of  the  patient.  It  should  further  be 
well  padded  with  wool  or  cotton,  and  covered  with  doe-skin,  so  that 
it  may  not  abrade  the  parts  to  which  it  is  applied  ;  and  there  should 
be  a  piece  let  in  on  either  side,  so  as  to  receive  and  support  the  tro- 
chanters without  entirely  covering  them ;  it  should  be  buckled  behind, 
and  padded  straps  be  carried  under  the  thigh,  and  across  the  tuberosity 
of  the  ischium,  on  either  side,  to  prevent  the  zone  from  slipping  up. 
I  do  not  mean  to  assert  that  I  have  ever  succeeded  in  completely  get- 
ting rid  of  the  inconveniences  of  congenital  dislocations  of  the  thigh- 
bones, but  I  have  prevented  their  increasing,  and  have  rendered 
supportable  what  I  could  not  cure.  The  testimony  of  some  patients 
to  the  value  of  this  treatment  has  been  of  a  most  unequivocal  charac- 
ter; for  being  worried  by  the  pressure  of  the  belt,  they  have  laid  it 
aside,  but  have  speedily  restored  it  again,  as  they  found  that  without 
it  they  had  •  neither  a  sense  of  firmness  in  the  hip,  nor  confidence  in 
walkino-." 

In  relation  to  which  opinions  the  same  excellent  writer  subsequently 
made  the  following  candid  admission :  "I  at  first  thought  that  no 
benefit  would  be  derived  in  these  cases  from  the  employment  of  con- 
tinual traction  on  the  lower  extremities,  for  reasons  already  stated; 
but  the  experiments  of  MM.  Lafond  and  Duval  tend  to  throw  some 
doubt  on  the  correctness  of  this  conclusion.  These  distinguished 
practitioners  tested  the  influence  of  extension,  in  their  orthopaedic  in- 
stitution, on  a  child  eight  or  nine  years  of  age,  who  was  the  subject 
of  double  congenital  dislocation  of  the  hip ;  after  the  uninterrupted 
employment  of  this  treatment  for  some  weeks,  I  satisfied  myself  that 
the  limbs  had  resumed  their  natural  length  and  direction ;  but  I  was 
not  a  little  astonished  to  find  that,  after  extension  had  been  persisted 
in  for  three  or  four  months  continuously,  the  greater  part  of  the  bene- 
ficial results  remained  for  several  weeks  undiminished.  It  would  be 
idle,  it  is  true,  to  generalize  on  this  single  case;  but  as  an  isolated 
example  of  the  utility  of  extension  it  is  interesting,  and  it  may  be  the 
forerunner  of  more  important  results.'" 

Since  which  time  Humbert  and  Jacquier,  who,  as  well  as  Duval 
and  Lafond,  confined  themselves  to  the  treatment  of  deformities,  claim 
to  have  met  with  equal  success  in  the  management  of  these  cases  by 

'  Dupuytren,  op.  cit.,  pp.  176-178 


CONGEISriTAL    DISLOCATIONS    OF    THE    HIP.  777 

extension  alone ;  and,  still  more  lately,  Guerin  of  Paris,  and  Pravaz 
of  Lyons,  by  the  adoption  of  the  same  general  principle  more  or  less 
modified,  have  added  new  triumphs,  and  greatly  enlarged  its  applica- 
tion. 

The  means  recommended  and  practised  by  Guerin,  are :  first,  pre- 
paratory extension  destined  to  elongate  the  muscles  as  much  as  pos- 
sible ;  second,  subcutaneous  section  of  the  muscles  which  mechanical 
extension  has  not  sufficiently  elongated  ;  third,  extension  of  the  liga- 
ments, and  even,  if  extension  does  not  suffice,  their  subcutaneous  sec- 
tion ;  fourth,  manoeuvres  destined  to  effect  reduction ;  fifth,  treatment 
designed  to  consolidate  the  reduction,  and  consisting  in  the  applica- 
tion of  the  apparatus  proper  to  maintain  the  extension  and  separation 
of  the  divided  tissues,  and  to  retain  the  head  of  the  femur  in  its  place  ; 
finally,  in  the  gradual  execution  of  movements  proper  to  complete  the 
coaptation  of  the  surfaces,  and  to  establish,  little  by  little,  th^  physio- 
logical movements  of  the  joint. 

Other  surgeons  have  confined  their  efforts  to  the  reduction  of  the 
dislocation,  and  they  have,  consequently,  abandoned  all  those  cases  in 
which,  owing  to  the  complete  absence  of  the  natural  socket,  or  to  the 
want  of  sufficient  mobility  in  the  limb,  the  reduction  wa§  deemed 
impossible ;  but  Guerin  has  gone  a  step  farther,  and  has  sought  to  es- 
tablish a  new  socket  upon  some  point  of  the  pelvic  bones  as  near  as 
possible  to  its  natural  articular  fossa.  "  The  means  which  I  adopt," 
says  Gudrin,  "  are  based  upon  a  recognition  of  the  processes  which 
nature  employs  for  the  attainment  of  the  same  purpose,  and  of  which 
mine  are  but  an  imitation.  I  have  shown  that  the  essential  condition 
of  the  formation  of  artificial  cavities  is  perforation  of  the  articular 
capsule,  and  the  placing  in  contact  of  the  luxated  extremity  with  an 
osseous  surface,  and  that  the  condition  of  the  maintenance  of  this  ab- 
normal rapport  is  the  intimate  adherence  of  the  borders  of  the  rent 
with  the  circumference  of  the  new  cavity.  Now  it  appeared  to  me 
that  art  could  realize,  in  all  points,  the  conditions  which  preside  at 
the  spontaneous  formation  of  artificial  joints.  To  this  end  I  commence 
by  practising  under  the  skin,  and  at  the  point  corresponding  to  that 
where  it  is  most  convenient  to  fix  the  luxated  extremity,  scarifications 
of  the  capsule,  down  to  the  bone  to  which  it  is  attached.  By  this 
means  the  dislocated  extremity  is  placed  in  immediate  contact  with 
the  bony  surface  upon  which  it  reposes.  It  makes  upon  this  point  a 
beginning  of  the  work  of  organization  resulting  from  the  adhesion 
and  fusion  of  the  scarified  points  with  the  corresponding  points  of 
this  surface.  Then,  in  order  to  circumscribe  and  imprison  the  lux- 
ated extremity,  in  this  place  of  election,  I  practise  all  about  deep  scari- 
fications, which  tend  to  excite  the  same  work  of  organization  and  to 
establish  fibro-cellular  adhesions  between  the  incised  borders  of  the 
capsule  and  the  contiguous  bony  surfaces. 

"Finally,  when  the  fibro-cellular  adhesions  are  supposed  to  be  suf- 
ficiently solid  to  resist  the  movements  of  the  new  articulation,  I  pro- 
voke, little  by  little,  the  development  of  the  cavity  destined  to  embrace 
the  luxated  extremity  by  the  means  which  nature  herself  employs  in 
50 


778  CONGENITAL    DISLOCATIONS. 

analogous  circumstances ;  that  is  to  say,  by  circumscribed  and  fre- 
quent movements  of  this  articulation."^ 

The  treatment  ought  to  be  commenced  as  early  as  possible,  no  ex- 
amples of  success  having  been  recorded  in  persons  over  fifteen  years 
of  age ;  while  the  youngest  child  whose  treatment  is  reported  as  suc- 
cessful was  three  years  of  age. 

For  the  purposes  of  making  the  requisite  extension,  and  of  main- 
taining the  bone  in  place,  Pravaz  (who  does  not,  however,  adopt 
Gudrin's  practice  of  establishing  for  the  head  of  the  bone  a  new 
socket,  but  only  seeks  to  reduce  and  maintain  it  in  its  old  socket)  has 
invented  several  forms  of  apparatus  adapted  to  the  dift'erent  stages  of 
progress  in  the  treatment.  Heine  of  Canustadt,  Gu^rin,  and  others  have 
also  suggested  special  contrivances  for  the  same  purpose ;  but  no  sur- 
geon who  understands  fully  the  principle  upon  which  the  cure  is  sup- 
posed to  "be  accomplished,  will  be  at  a  loss  for  apparatus  suitable  for 
making  the  necessary  extension,  or  for  maintaining  the  reduction 
when  once  it  has  been  effected. 

The  length  of  time  required  for  the  completion  of  a  cure,  where  a 
cure  is  possible,  must  vary  according  to  the  age  and  health  of  the 
patient,  and  according  to  the  pathological  condition  of  the  joint,  and 
may  be  found  to  extend  from  a  few  months  to  one  or  more  years.  It 
is  unnecessary  to  say  that  where  the  accomplishment  of  the  cure  de- 
mands a  period  of  several  years,  the  treatment  must  be  intermittent 
and  greatly  varied,  so  as  to  suit  all  the  changing  circumstances  in  the 
condition  of  the  patient. 

Finally,  if  after  a  fair  trial  we  fail  to  accomplish  a  cure,  or  if  the 
condition  of  the  child  will  not  warrant  even  the  attempt,  we  ought  as 
far  as  possible  to  seek  to  prevent  an  increase  of  the  deformity  by 
such  means  as  our  ingenuity  may  suggest,  or  by  such  judicious  appli- 
ances and  general  management  as  we  have  seen  recommended  by 
Dupuytren. 

South  says  that  he  has  seen  one  case  of  double  dislocation  in  which 
the  walking  was  at  first  extremely  difficult,  but  from  the  fifteenth 
year  and  onwards  the  patient  so  improved,  that  at  the  twentieth  year 
scarcely  any  trace  of  the  peculiar  gait  could  be  discovered.^ 

§  14.  Congenital  Dislocations  of  the  Patella. 

Palletta  found  a  dislocation  of  the  patella  in  the  cadaver  of  a  young 
man,  which  he  supposed  to  be  congenital.^  Michaelis  has  reported 
two  cases ;  one  in  a  j^oung  man  of  seventeen  years,  and  the  other  in 
a  girl  of  fourteen,  each  of  whom  affirmed  that  it  had  existed  from 
birth.*  Both  of  these  examples  presented  themselves  at  the  hospital 
on  account  of  hydrarthrosis  of  the  knee-joints,  and  Malgaigne,  who 
had  himself  seen  a  similar  case,  is  disposed  to  regard  them  all  as 
examples  of  pathological  rather  than  congenital  luxations.     Pdriat 

'  Gueriu,  op.  cit.,  pp.  81-3. 

2  South,  Note  to  Chelins,  op.  cit.,  vol.  ii.  p.  245. 

3  Palletta,  Exercitatioues  Patliologicse,  p.  91. 

1  Michaelif,  Eev.  M^d.-Cliirurg.,  torn.  xv.  p.  56. 


CONGENITAL    DISLOCATIONS    OF    THE    KNEE.  779 

reports  a  case  in  which  the  dislocation  was  only  produced  by  walk- 
ing, and  in  relation  to  the  authenticity  or  pertinence  of  which  Mal- 
gaigne  seems  also  to  entertain  a  doubt.^ 

South  says  that  he  has  seen  a  congenital  dislocation  on  both  legs, 
in  an  aged  man.  The  patellee  rested  entirely  upon  the  outer  faces  of 
the  external  condyles,  leaving  the  front  of  the  knee-joint  completely 
uncovered.  When  the  limbs  were  extended  the  patellae  could  be 
easily  made  to  resume  their  natural  positions,  but  on  the  patient's 
making  the  slightest  movement  they  were  again  displaced.  The 
knees  were  very  much  inclined  inwards,  the  feet  outwards,  and  his 
gait  was  difficult  and  unsteady.^ 

Dr.  Saml.  Gr.  Wolcott  of  Utica,  N.  Y.,  informs  me  that  he  has  under 
observation  a  case  similar  to  the  one  reported  by  South,  in  a  healthy 
and  otherwise  well  formed  and  well  developed  boy,  set.  4.  "  When 
the  legs  are  flexed  the  patellae  slip  outwards  upon  the  external  con- 
dyles of  the  femurs,  and  on  extending  the  legs  the  patellae  resume 
their  positions  in  front  of  the  knee-joints.  This  occurs  at  every  step 
he  takes.  The  knees  are  strongly  inclined  inwards,  and  the  feet  out- 
ward. His  step  is  very  insecure,  and  if  accidentally  he  hits  his  feet  or 
legs  against  anything  in  walking,  he  invariably  falls." 

The  most  remarkable  example,  however,  has  been  reported  by  Dr. 
E.  J.  Caswell,  of  Providence,  E.  I.,  inasmuch  as  no  less  than  five 
members  of  the  same  family  have  double  congenital  dislocations  of 
the  patellae.  The  man  who  was  the  subject  of  Dr.  Caswell's  special 
examination  is  43  years  old,  and  possessed  of  a  good  constitution. 
The  patellee  lay  upon  the  outer  condyles,  and  are  movable,  performing 
their  functions  nearly  as  well  as  if  placed  in  their  proper  positions. 
He  walks  without  difficultj  upon  level  ground,  or  upon  an  ascending 
plane,  but  great  caution  is  required  in  descending.  The  right  patella 
is  longer  and  less  movable  than  the  left,  and  the  muscles  of  both  of 
his  lower  extremities  are  small.  "In  addition  to  his  labor  as  an 
operative,  he  cultivates  a  small  farm."  Dr.  Caswell  examined  his 
son  and  found  the  same  malposition,  but  less  marked  than  in  the  case 
of  the  father.  The  father  then  stated  that  his  own  father,  his  sister, 
and  the  son  of  his  half  brother  by  the  same  father,  had  a  similar  de- 
formity.^ 

§  15.  Congenital  Dislocations  or  the  Knee. 

The  head  of  the  tibia  has  been  found,  at  birth,  dislocated  forwards, 
backwards,  inwards,  outwards,  inwards  and  backwards,  outwards  and 
backwards,  and  simply  rotated  inwards. 

Most  of  these  luxations  were  incomplete ;  and  of  them  all,  the  dis- 
location forwards  has  been  observed  much  the  most  often. 

A  subluxation  forwards  of  the  head  of  the  tibia  has  been  seen  by 
Guerin  in  a  foetal  monster,  accompanied  with  extreme  retraction  of 

'  P^riat,  Malgaigne,  op.  cit.,  torn.  ii.  p.  933. 

2  South,  Note'to'Chelius,  op.  cit.,  vol.  ii.  p.  247. 

3  Caswell,  Anier.  Journ.  Med.  Sci.,  July,  1865. 


780  CONGENITAL    DISLOCATIONS. 

the  extensor  muscles  of  the  leg}  Cruveilhier  has  dissected  a  foetus 
affected  with  a  similar  subluxation.^ 

In  these  examples  the  displacement  forwards  at  the  articular  surface 
was  but  slight,  and  the  anterior  flexion  of  the  limb  inconsiderable; 
but  when  the  dislocation  is  complete,  or  nearly  so,  the  deformity  is 
in  all  respects  very  much  increased;  as  the  following  examples  will 
illustrate: — 

Dr.  D.  H.  Bard,  of  Troy,  Vermont,  has  reported  an  example  of 
complete  anterior  luxation  of  the  tibia,  seen  by  himself,  in  a  new-born 
infant.  The  leg  was  found  drawn  forwards  upon  the  thigh  at  an  acute 
angle,  so  that  the  toes  pointed  toward  the  face  of  the  child,  and  the 
bottom  of  the  foot  was  directed  forwards.  By  the  application  of 
moderate  force,  the  limb  could  be  straightened  and  even  flexed  com- 
pletely. These  motions  inflicted  no  pain.  It  was  especially  noticed 
that  in  bringing  down  the  leg  from  its  position  of  extreme  anterior 
flexion  (extension)  more  force  was  required  in  the  first  part  of  the 
manoeuvre  than  in  the  last ;  and  that  if,  having  brought  the  leg  down, 
it  was  left  to  itself,  it  immediately  resumed  the  abnormal  position, 
moving  at  first  slowly,  but  after  a  time  much  more  rapidly. 

The  limb  was  confined  by  bandages  for  a  short  time,  and  it  did  not 
afterwards  show  any  disposition  to  return  to  its  unnatural  position. 
The  child  did  well,  and  when  it  began  to  use  its  legs,  no  difference 
could  be  discovered  between  them.^ 

J.  Youmans,  of  Portage ville,  N.  Y.,  reports  a  similar  case  which 
occurred  in  his  own  practice.  A  healthy  woman  was  delivered,  on  the 
]  6th  of  Aug.  1859,  of  a  full  grown  female  child,  whose  left  knee  was 
so  completely  dislocated  that  the  toes  rested  upon  the  anterior  part  of 
the  thigh  near  the  groin.  Dr.  Youmans  immediately  took  hold  of 
the  limb  and  brought  it  to  its  natural  form,  but  as  soon  as  he  relin- 
quished his  hold,  it  flew  back  to  its  original  position.  Having  again 
straightened  the  leg  it  was  retained  in  place  easily  by  two  pieces  of 
whalebone  tied  upon  each  side  of  the  thigh  and  body.  Some  soreness 
and  swelling  ensued,  and  it  was  some  weeks  before  the  splint  could 
be  safely  removed.  At  the  time  of  the  report,  Oct.  11,  1860,  the  child 
was  using  the  limb  with  as  much  freedom  and  dexterity  as  other 
children  of  her  own  age. 

In  the  report  particular  attention  is  called  to  the  disposition  on  the 
part  of  the  limb  to  resume  its  unnatural  position  with  a  spring,  show- 
ing contraction  of  the  anterior  muscles  of  the  thigh;  to  the  fact  that 
the  patella  of  this  knee  was  smaller  than  the  other,  and  that  the  skin 
on  the  front  of  the  knee  was  wrinkled  as  it  is  usually  back  of  the 
knee  in  fat  children."* 

I  have  mentioned  a  case  of  congenital  forward  dislocation  of  both 
tibiae  which  came  under  my  observation,  in  the  section  on  congenital 
dislocations  of  the  hip,  and  I  have  recently  seen  a  case  of  congenital 

'  Gu^rin,  op.  cit.,  p.  33. 

2  Cruveilhier,  Atlas  de  I'Anat.  Patholog.,  2e  livr.,  pi.  2. 

3  Bard,  Amer.  Jouru.  Med.  Sci.,  Feb.  1835,  p.  555,  from  Bost.  Med.  and  Surg. 
Journ.  Not.  26,  1834. 

^  Youmans,  Bost.  Med.  and  Surg.  Journ.,  Oct.  25,  1860,  vol.  63,  p.  250. 


CONGENITAL    DISLOCATIONS    OF    THE    KNEE.  781 

subluxation  of  both  tibias  backwards,  occasioned  by  contraction  of  the 
hamstrings.  Section  of  the  muscles  restored  the  bones  nearly  to  their 
normal  position. 

Chatelain  was  consulted  in  relation  to  a  similar  case,  in  which  the 
restoration  of  the  limb  to  its  natural  position  was  also  easily  effected, 
and  by  means  of  three  metallic  splints,  applied  during  about  fifteen 
days,  the  cure  was  consummated.  Chatelain  directed,  however,  that 
the  leg  should  be  kept  flexed  upon  the  thigh  eight  days  longer.^ 

Kleeberg  found  a  child  with  the  leg  so  much  flexed  forwards  (ex- 
tended) upon  the  thigh  that  the  popliteal  region  became  the  lowest 
point  of  the  limb;  in  front  and  above  the  articular  extremity  of  the 
tibia  could  be  felt,  and  the  condyles  of  the  femur  made  a  correspond- 
ing projection  behind  into  the  popliteal  space.  This  was  plainly  an 
example  of  complete  luxation;  and,  contrary  to  what  was  observed 
in  Bard's  case,  flexion  of  the  limb  backwards  was  difficult  and  painful. 

The  treatment  was  commenced  by  securing  the  limb  in  a  straight 
position  by  means  of  a  splint  and  roller  ;  subsequently,  Kleeberg  car- 
ried the  limb  back  to  an  obtuse  angle,  and  finally,  it  was  kept  eight 
days  in  a  position  of  extreme  flexion.  A  complete  cure  was  said  to 
have  been  accomplished  in  about  two  weeks.^ 

Guerin  has  seen  a  subluxation  backwards,  accompanied  with  a  slight 
rotation  of  the  head  of  the  tibia  outwards,  in  a  girl  fourteen  years  old; 
and  which,  he  affirms,  was  congenital,  characterized  by  a  permanent 
flexion  (backwards)  of  the  leg  upon  the  thigh,  and  a  sliding  of  the 
condyles  of  the  tibia  backwards. 

This  girl  was  under  Gruerin's  treatment,  but  with  what  result  is  not 
stated. 2 

Chaussier  found  both  tibige  displaced  backwards  in  an  infant  other- 
wise deformed.* 

Kobert  speaks  of  an  example  of  lateral  subluxation  in  a  man,  which 
had  existed  from  birth.  The  right  knee  was  thrown  inwards,  and  the 
left  outwards.' 

Guerin  "operated"  publicly  upon  a  child,  two  years  old,  who  had  a 
congenital  dislocation  of  the  head  of  the  tibia  backwards  and  inwards, 
accompanied  with  a  slight  rotation  of  the  leg  inwards.^  In  what  man- 
ner he  operated,  and  with  what  result,  he  does  not  inform  us. 

The  same  writer  speaks  of  a  subluxation  backwards  and  outwards, 
with  rotation  in  the  same  direction,  a  deformity  which,  he  affirms,  is 
very  frequent,  and  which  appears  especially  after  birth,  although  the 
causes  which  produce  it  have  given  their  first  impulse  during  intra- 
uterine life. 

The  case  quoted  from  Eobert,  by  Malgaigne,  as  an  example  of  dis- 
location inwards,  seems  to  have  been  rather  a  case  of  semi-rotation 
of  the  articular  surfaces,  the  inner  condyle  being  thrown  back  into 
the  popliteal  space,  while  the  outer  condyle  still  retained  its  natural 
position. 

'  Chatelain,  Bibliotheqne  Med.,  torn.  Ixxv.  p.  85. 

2  Kleeberg,  Malgaigne,  op.  cit.,  p.  983.      ^  Robert,  Malg.,  op.  cit.,  p.  985. 

3  Guerin,  sur  les  Lux.  Congen.,  p.  33.        ^  Guerin,  sur  les  Lux.  Congeu.,  p.  33. 
*  Chaussier,  Malgaigne,  op.  cit.,  p.  884. 


782  CONGENITAL    DISLOCATIONS. 

§  16.  Congenital  Dislocations  op  the  Tarsal  Bones. 

Under  this  general  term  may  be  included  all  those  varieties  of  sub- 
luxation of  the  several  bones  which  compose  the  tarsus,  and  which  are 
known  as  examples  of  talipes  or  club-foot;  such  as  tibio-astragaloid 
luxations,  astragalo-scaphoid,calcaneo-astragaloid,  calcaneo-cuboid,  &c. 

Although  these  deformities  may  properly  enough  claim  a  place  in 
a  chapter  on  congenital  dislocations,  they  have  so  long  been  the  sub- 
jects of  special  treatises  as  to  justify  their  exclusion  from  the  present 
volume. 

§  It.  Congenital  Dislocations  of  the  Toes, 

Observed  occasionally  at  the  metatarso-phalangeal  articulations;  the 
articular  facets  of  the  first  phalanges  suffering  a  subluxation  upwards, 
or  laterally  upon  the  corresponding  metatarsal  bones. 

Guerin  has  noticed  especially  a  congenital  lateral  subluxation  of 
the  great  toe.^ 

'  Guerin,  op.  cit.,  p.  34. 


INDEX. 


PART  L-FRACTURES. 


Abscess  in  fracture  of  the  sternum,  169 
Acetabulum,  343 
Acromion  process,  208 
Amesbury's  thigh  splint,  399 
AnEBsthetics,  use  of,  in  diagnosis,  37 
Anatomical  neck  of  humerus,  215 
Anaplasty  in  fractures  of  the  septum  narium,  96 
Anchylosis  after  Colles's  fracture,  282 

after  fractures  of  elbow,  266 

excision  for  anchylosis  of  knee,  444 
Apparatus  immobile,  54 

in  fractures  of  the  leg,  463 
Arytenoid  cartilages,  fractures  of,  139 
Ashhurst,  fracture  of  astragalus,  478 
Astragalus,  476 
Atlas,  164 

and  axis,  164 
Axis,  161 
Ayres,  compound  fracture  of  clavicle,  187 

Badly  united  fracture  of  leg,  474 
Bartlett's  apparatus  for  broken  clavicle,  198 
Barton's  bran  dressing,  61,  473 

bandage  for  fractured  jaw,  129 

trephining  vertebrfe,  148 

fracture  of  lower  end  of  radius,  281 
Base  of  acetabulum,  344 
Bauer's  wire  splints,  471 
Beans,  lower  jaw,  124 
Bending  of  bones,  72 
Biceps,  displacement  of  long  head,  576 

rupture  of,  576 
Bigelow,  stellate  fracture  of  lower  end  of  ra- 
dius, 279 

rim  of  acetabulum,  345 
Boardman,  fracture  of  zygoma,  107 
Body  of  the  scapula,  202 
Bodies  of  the  vertebras,  151 
Bond's  elbow  splint,  251 

radius  splint,  285 
Bosworth,  Frank,  tracheotomy  in  fracture  of 

lower  jaw,  110 
Box  for  leg,  473 
Boyer's  thigh  splint,  399 
Brainard,  perforator,  70 
Buck,  lower  jaw,  119 

thigh  splint,  407 
Burge,  patella,  443  ' 

CALCANEUir,  477 
Carpal  bones,  327 
Cartilages,  177 


Carved  splints,  radius,  291 
Cervical  ligaments,  strains  of,  157 

vertebrae,  bodies  of  five  lower,  155 

axis,  161 

atlas,  163 

atlas  and  axis,  164 
Children,  fracture  of  femur,  426 
Chronic  rheumatic  arthritis,  367 
Clark's  case  of  fracture  of  pelvis,  337 
Clark,  fracture  of  humerus,  239 
Clavicle,  178 

partial  fractures,  179 

repair  of  fractures,  185 
Cline,  trephining  vertebrse,  148 

fracture  of  atlas,  164 
Coates,  fracture  bed,  418 

bran  dressings,  61 
Coccyx,  351 
Colles's  fracture,  274 
Comminuted  fractures,  60 
Common  signs  of  fracture,  33 
Compound  fractures,  60 

forearm,  327 

thigh,  Gilbert  on,  408 

thigh,  author's  opinion,  428 

patella,  438 

tibia  and  fibula,  464 
Concussion  of  spinal  marrow,  157 
Condyles  of  humerus,  256 
internal,  261 
external,  263 
base,  245 
base  and  between  condyles,  253 

of  femur,  428 

external,  428 
internal,  429 
base,  431 

between  condyles,  431 
Congenital,  31,  234,  445 

Cooper,  Sir  Astley,  fracture  of  olecranon  pro- 
cess, 315 

neck  of  femur  within  capsule,  361 

patella,  441 
Coracoid  process,  211 
Coronoid  process  of  ulna,  301 
Cotyloid  cavity,  343 

Counter-extension  by  adhesive  plaster,  403 
Cradle  for  leg,  472 

Crandall,  extension,  fracture  of  leg,  469 
Cricoid  cartilage,  138,  140 
Crosby,  neck  of  femur  within  capsule,  371 

external  condyle,  428 


784 


INDEX  —  FEACTURES. 


Daniels'  fracture-bed,  419 
Deformities  of  legs,  474 
Delayed  or  non-union,  62 

humerus,  234 

tibia,  470 
Dextrine,  55 
Diagnosis,  general,  33 
Dieffenbach,  tenotomy  in  fracture  of  olecranon 

process,  317 
Dislocation  of  humerus,  differential  diagnosis, 

227 
Division  of  fractures,  general,  27 
Dorsal  vertebra;,  154 
Dorsey,  fracture  of  patella,  440 
Dugas,  sign  of  dislocation  of  humerus,  228 
Dupuytren's  case  of  fracture  of  a  dorsal  ver- 
tebra, 155 

body  of  a  lower  cervical  vertebra,  156 

dressing  for  fracture  of  fibula,  451 

Elbotv  splint,  Physick's,  249 

Kirkbride's,  250 

Eose's,  250 

AVelch's,  250 

Bond's,  251 

the  author's,  252 
Else,  fracture  of  axis,  161 
Emphysema  in  fracture  of  ribs,  175 
Epicondyle  of  humerus,  external,  260 

internal,  256 
Epiphyseal  separations,  28 

acromion,  208 

humerus,  upper  end,  221 
lower  end,  245 

femur,  upper  end,  356 
lower  end,  433 

trochanter  major,  384 
Epiphyses,  sternum,  167 

scapula,  210 

humerus,  222 

radius,  296 

ulna,  305 

OS  innominatum,  335 

femur,  352 

tibia,  445 

fibula,  449 
Epitrochlea,  256 
Etiology,  general,  29 
Eve,  non-union  of  ribs,  174 

patella,  435 
Exciting  causes,  general,  29 
Experiments  on  bending,  73 

on  partial  fractures,  78,  82 
External  epicondyle  of  humerus,  260 

condyle  of  humerus,  263 
femur,  428 
Extension  of  thigh  by  adhesive  plaster,  417 

Fanning,  N.,  humerus,  233 
Fauger,  Colles's  fracture,  285 
Felt  splints,  51 
Femur,  352 

neck,  within  capsule,  353 

neck,  anatomy  of,  George  K.  Smith,  365 

differential  diagnosis,  357 

without  capsule,  376 

trochanter  major  and  base  of  neck,  383 

epiphysis  of  trochanter  major,  384 

shaft,  386 

in  children,  426 

external  condyle,  428 

internal  condyle,  429 


Femur — 

between  condyles,  431 

base  of  condyles,  431 

separation  of  lower  epiphysis,  433 
Fibula,  449 
Fingers,  331 
Fissures,  84 

neck  of  femur,  352 
Fitch,  fracture  of  lower  jaw,  129 
Flagg's  thigh  apparatus,  405 
Floating  cartilages,  in  knee-joint,  700 
Forearm,  318 

Fore's  case  of  fracture  of  hyoid  bone,  134 
Four-tailed  bandage  for  broken  jaw,  130 
Fracture  beds,  418 

Jenks,  431 

Hewson,  418 

Barton,  418 

Coates,  418 

Daniels,  419 

Burges,  411 

Crosby,  421 
Fracture-box,  473 

Gangrene,  after  fracture  at  base  of  condyles 
of  humerus,  249 

Dupuytren's  cases  after  fracture  of  radius, 
292 

Robert  Smith's  cases,  293 

Norris,  294 

after  fracture  of  forearm,  320 

leg,  from  tight  roller,  412 

patella,  441 

from  tight  bandages,  448 

leg  from  tight  bandages,  461 

from  use  of  "apparatus  immobile,"  464 
Gibson,  bandage  for  fractured  jaw,  129 

fracture  of  clavicle,  188 

of  coracoid  process,  211 
Gilbert,  apparatus  for  broken  femur,  416 

leg,  468 
Glenoid  cavity  of  scapula,  comminuted,  207 
Granger,  fracture  of  epicondyle,  256 
Greater  tubercle  of  humerus,  219 
Gunning's  interdental  splint,  124 
Gunshot  fractures,  483 

treatment  in,  486 
Gutta-percha  splints,  52 

Harris,  separation  of  upper  maxillary  bones, 

101 
Harrold,  lumbar  vertebrae,  154 
Hartshorne,  Edward,  clavicle,  193 
Hartshorne,  Joseph  E.,  thigh  apparatus,  408 
Hays,  radial  splint,  285 
Ilayward,  lower  jaw,  120 
Head  of  femur,  353 

of  radius,  270 

and  anatomical  neck  of  humerus,  215 

and  neck  of  humerus,  longitudinal  frac- 
ture, 219 
Hewson,  fracture-bed,  418 
Hodge,  thigh-splint,  416 
Hodgen's  fracture-cradle,  487 

"        wire,  suspension  splint,  403 
Hodges,  head  of  radius,  470 
Horner,  thigh  apparatus,  407 
Humerus,  213 

anatomical  neck,  215 

head  and  neck,  215-219 

tubercles,  219 

longitudinal  fracture  ofhead  and  neck,  219 


INDEX  —  FRACTURES. 


785 


Humerus — 

surgical  neck,  221 

upper  epiphysis,  221 

differential  diagnosis,  227 

shaft,  234 

lower  epiphysis,  245 

base  of  condyles,  245 

with  splitting  of  condyles,  253 

condyles,  256 

internal  epicondyle,  256 

external  epicondyle,  260 

internal  condyle,  261 

external  condyle,  263 

delayed  union,  266 

dislocation  of,  228 
Hutchinson,  leg  splint,  467 
Hutchinson,  J.  C,  fracture  of  spine,  149 
Hyoid  bone,  133 

Ilium,  340 

Immovable  apparatus,  54     < 

leg,  463 
Impacted  fractures,  28 

head  and  neck  of  humerus,  215 

tubercles,  219 

neck  of  femur  within  capsule,  355 
without  the  capsule,  377 
Incomplete  fractures,  72 
Inferior  maxilla,  109 

Interstitial  absorption  of  neck  of  femur,  367 
Internal  condyle  of  humerus,  261 

femur,  429 
Interdental  splints,  122 
Intra-uterine  fracture,  35,  235,  445 

fracture  of  tibia,  445 
Ischium,  398 

Jackson,  acromion  process,  209 
Jarvis's  adjuster,  467 
Jenks,  fracture-bed,  431 
Johnson,  neck  of  femur,  364 

Key,  lumbar  vertebroe,  154 
Kingsley,  fracture  of  lower  jaw,  128 
Kirkbride,  elbow  splint,  250 

Larynx,  fracture  of,  138 

Lausdale,  patella,  444 

Lente,  fracture  of  dorsal  vertebra,  155 

femur,  410 

non-union,  67 

pelvis,  335 
Lewitt,  patella,  439 
Liston,  thigh  splint,  396 

leg  splint,  471 
Lockwood,  fracture  of  humerus  at  birth,  234 
Long  head  of  biceps,  displacement  of,  576 
Long  splints,  48 
Lonsdale,  extension  in  fracture  of  humerus,  237 

patella,  442 
Lower  jaw,  109 

Malar  bone,  97 

McDowell,  remarkable  displacement  of  head 
of  humerus,  215 

separation  of  upper  epiphysis,  223 
Malgaigne,  apparatus  for  fracture  of  leg,  473 
Many-tailed  bandage,  47 
March,  acromial  separations,  209 
Martin,  fracture  of  humerus,  238 
Maxilla,  superior,  100 

inferior,  109 


Metacarpus,  328 

Metatarsus,  481 

Metallic  splints,  48 

Monahan,  fracture  of  astragalus,  476 

Moore,  Colles'  fracture,  280 

fracture  of  clavicle,  195 
Morbus  coxa3  senilis,  367 
Morland,  statistics  of  fracture  of  tibia  and 

fibula,  455 
Mott,  prognosis  in  Colles'  fracture,  283 

electricity  in  non-union,  67 
Mussey,  fracture  of  coracoid  process,  211 
Mutter's  "clamp,"  123 

neck  of  radius,  270 

Neck  of  femur,  353 

within  capsule,  353 

prognosis,  361 

G.  K.  Smith  on,  365 

without  capsule,  376 
Neck  of  humerus,  anatomical,  215 

surgical  neck,  221 
Neck  of  lower  jaw,  111 
Neck  of  radius,  267 
Neck  of  scapula,  206 

signs  of  fracture,  228 
Neill,  maxilla  superior,  105 

coracoid  process,  211 
thigh,  404 

leg,  simple  fracture,  467 

compound  fracture,  468 
Nelaton,  radial  splint,  285 
Non-union,  62 

humerus,  240 

lower  jaw,  117 

ribs,  173 
Norris,  delayed  and  non-union,  62 

astragalus,  479 

gangrene  from  bandages,  294 

tibia,  448 
Nose,  fracture  of,  89 
Nott,  wire  splints,  48 

thigh  apparatus,  401 

Odontoid  process  of  axis,  161 
Olecranon  process,  310 

tenotomy,  317 
Ossa  nasi,  89 

Packard,  J.  A.,  clavicle,  193 

Palmer's  thigh  splint,  402 

Partial  fracture,  76 

Patella,  434 

Pelvis,  334 

Phalanges  of  fingers,  331 

toes,  482 
Pubes,  335 

PiADins,  267 

Radius  and  ulna,  318 

Reduction  of  fractures  :    general   considera 

tions,  44 
Refracture  of  badly-united  legs,  474 
Repair  of  fracture,  38 
Resection  for  badly  united  fractures,  474 
Rheumatic  arthritis,  chronic,  367 
Rhinoplasty,  96 
Ribs,  172 

cartilages  of,  177 
Rim  of  acetabulum,  347 
Rodet,  neck  of  femur,  354 
Rogers,  trephining  vertebra;,  149 


786 


INDEX — FRACTURES. 


Roller,  46 

Rose,  elbow  splint,  250 

Sacrum, 349 

Sacro-iliae  symphysis,  335 

Salter's  cradle  for  leg,  477 

Sargent,  separation  of  upper  maxillary  bones, 

101 
Sayre,  L.  A.,  clavicle,  196 
Scapula,  202 

body, 202 

neck,  206 

acromion  process,  20S 

coracoid  process,  211 

epiphyses  of,  210 
Scultetus,  bandage,  46 
Semeiology,  general,  33 
Septum  narium,  94 
Setting  bones,  44 
Seutin,  dressing,  54 
Shaft  of  humerus,  234 

radius,  271 

ulna,  297 

femur,  386 
Shoulder-joint;  differential  diagnosis  of  acci- 
dents, 227 
Shrady,  radius  splint,  286 
Side  splints,  48 
Sling  for  broken  jaw,  130 
Smith,  E.  P.,  radial  splint,  286 
Smith,  Nathan  R.,  fracture  of  femur,  402 
Smith,  Robert,  head  of  humerus,  217 
Smith,  Stephen,  fracture  of  lower  jaw,  116 

odontoid  process  of  axis,  164 
Smith,  Geo.  K.,   insertion  of  capsule  of  hip- 
joint,  &c.,  365 
Spinal  marrow,  concussion,  157 
Spinous  processes  :  vertebrae,  142 

ilium,  340 
Splints,  48 
Starch  bandage,  54 
Sternum,  165 

Stone,  base  of  condyles  and  resection,  255 
Styloid  process  of  radius,  280 
Surgical  neck  of  humerus,  221,  230,  232 
Swing  box  for  leg,  472 
Symphyses  of  pelvis,  334 

pubes,  335 

sacro-iliac,  350 
Symphysis  pubis,  separation  of,  334 

Tarsus,  476 

astragalus,  476 

calcaneum,  477 
Tenotomy  in  fractures  ofolecranon  process,  317 


Thompson,  fracture  of  lumbar  vertebrte,  153 

Thyroid  cartilage,  138 

Thyroid  and  cricoid  cartilages,  138 

Tibia,  444 

Tibia  and  fibula,  453 

Toes,  482 

Transverse  processes  of  spine,  144 

Treatment  of  fractures,  general,  44 

Trephining  for  fracture  of  vertebrae,  148 

Trochanter  major,  383 

Trochlea  of  humerus,  361 

Tubercles  of  humerus,  219,  229,  231 

Ulna,  resection  of,  295 
Ulna,  297 

shaft,  297 

coronoid  process,  301 

olecranon  process,  310 
Upper  epiphysis,  humerus,  221 

femur,  356 
Upper  maxillary  bones,  100 

Vanderveer,  fracture  in  utero,  33 
Vandeventer,  fracture  of  vertebral  arch,  146 
Velpeau,  mode  of  dressing  fractures  with  dex- 
trine and  rollers,  55 
Vertebral  arches,  145 
Vertebra),  142 

spinous  processes,  142 
transverse  processes,  144 
vertebral  arches,  145 
bodies,  151 

lumbar,  153 
dorsal,  154 
cervical,  155 
axis,  161 
atlas,  163 
atlas  and  axis,  164 

Warren  on  anchylosis  at  elbow-joint,  266 

Water-beds,  160 

Watson,  fracture  of  lower  jaw.  111 

lower  epiphysis  of  humerus,  245 

patella,  437 
Weber,  plaster  of  Paris  bandage,  59 
Wells,  internal  condyle  of  femur,  429 
Whittaker,  pelvis,  338 
Wire-beds,  160 
Wire  splints,  48 

Wire  rack  for  fracture  of  leg,  473 
Wood,  fracture  of  patella,  440 
Wooden  splints,  49 
Wrist,  327 

ZvGOMATic  arch,  106 


INDEX — DISLOCATIONS. 


787 


PART  II.-DISLOCATIONS. 


Anaesthetics,  500 
Ancient  luxations,  494 

inferior  maxilla,  504 

spine,  512 

clavicle,  outer  end,  534 

humerus,  559 

head  of  radius  forwards,  581 

radius  and  ulna  backwards,  591 

thumb,  620 

femur,  686 
Andrews,  inferior  maxilla,  502 
Ankle-joint,  713 
Anomalous  dislocations  of  the  hip,  678.     See 

Femur. 
Anterior  oblique  dislocation,  680 
Astragalus,  727 
Atlas,  dislocations  of,  519 
Ayres,  dislocation  of  cervical  vertebra,  517 

Batchelder,  head  of  radius,  579,  584 

thumb,  625 
Biceps,  rupture  or  displacement  of,  576 
Bigelow,  H.  J.,  on  dislocations  of  hip,  637 
Blackman,  ancient  dislocations  of  humerus, 
563 

femur,  reduced  after  six  months,  686 
Bloxham's  dislocation  tourniquet,  651 
Brainard,  reduction   of  ancient   luxation    of 
elbow,  596 

Calcaneum,  dislocation  of,  736 
Canton,  radius  and  ulna  forwards,  605 
Carpus,  606 

backwards,  608 
forwards,  611 
congenital,  771 
Carpal  bones  among  themselves,  615 
Carpo-metacarpal  articulation,  617 
Cartilages,  of  ribs  from  one  another,  524 

in  knee-joint,  711 
Caswell,  dislocation  of  patella,  779 
Clavicle,  dislocations  of,  524 

sternal  end  forwards,  524 

sternal  end  upwards,  528 

sternal  end  backwards,  530 

acromial  end  upwards,  532 

acromial  end  downwards,  537 

under  coracoid  process,  538 

both  ends,  539 

congenital,  766 
Clove-hitch,  500 
Compound  pulleys,  500 
Compound  dislocations  of  the  long  bones,  743 

reduction  in,  749 

non-reduction  in,  752 

amputation  in,  752 

tenotomy  in,  753 

resection  in,  753 
Congenital  dislocations ;  general  observations 
and  history,  758 

general  etiology,  760 

inferior  maxilla,  761 


Congenital  Dislocations — 

spine,  764 

pelvic  bones,  765 

sternum,  765 

clavicle,  766 

shoulder,  766 

radius  and  ulna  backwards,  770 

head  of  radius,  770 

wrist,  771 

fingers,  772 

hip,  772 

patella,  778 

knee,  779 

tarsus,  782 

toes,  782 
Cooper,  Sir  Astley,  method  of  reducing  dislo- 
cation of  humerus,  556 
Coxo-femoral  dislocations,  632.     See  Femur. 
Crosby,  dislocation  of  thumb,  624 

ancient  dislocation  of  elbow,  597 
Cuboid,  dislocations  of,  737 
Cuneiform  bones,  dislocation  of,  738 

Damainville,  statistics  of  dislocations  of  fe- 
mur, 652 
Direct  causes  of  dislocations,  495 
Dislocations,  493 

Division  and  nomenclature  of  dislocations,  493 
Double  dislocation  of  lower  jaw,  501 
Dupierris,  femur  reduced  after  six  months,  686 
Dynamometer,  651 

Elbow-joint,  588 

Everted  dorsal  dislocation  of  femur,  640 
Exciting  causes,  general,  495 
Extension  by  a  twisted  rope,  500,  650 

Femur,  dislocation  of,  632 

dislocation  on  dorsum  ilii,  634 

reduction  by  manipulation,  641 

reduction  by  extension,  648 
dislocation  into  great  ischiatic  notch,  660 
below  the  tendon,  663 
dislocation  into  foramen  thyroideum,  668 
dislocation  upon  the  pubes,  674 
anomalous  dislocations  of  the  femur,  678 

downwards  and  backwards  upon  the 
body  of  the  ischium,  682 

downwards  and  backwards  into  lesser 
ischiatic  notch,  682 

behind  the  tuber  ischii,  674 

directly  up,  678 

directly  down,  683 

forwards  into  perineum,  684 

ancient  dislocations,  686 

partial  dislocations,  690 

with  fracture,  691 

in  children,  416,  632 

congenital,  772 

voluntary,  694 
Fenner,  dislocation  of  femur  on  dorsum  ilii, 
636 


7i 


INDEX — DISLOCATIONS. 


Fibula,  upper  end  forwards,  725 

backwards,  726 

lower  end,  727 
"Fifth"  dislocation  of  femur,  682 
Fingers,  dislocations  of  first  phalanx,  620,  628 

second  and  third,  629 

congenital,  772 
Foot,  dislocation  outwards,  714.     See  Tibia. 
Fountain,  dislocation  of  femur  upon  pubes,  676 

Gazzam,  rotation  of  patella  on  its  inner  mar- 
gin, 701 
General  division,  493 
General  direct  or  exciting  causes,  495 
General  predisposing  causes,  494 
General  prognosis,  498 
General  pathology,  497 
General  treatment,  498 
General  symptoms,  495 
Gibson,  ancient  dislocation  of  humerus,  564 
Gilbert,  A.  W.,  dislocation  of  lower  jaw,  502 
Grant,  astragalus,  733 
Graves,  dislocation  of  dorsal  vertebrte,  512 
Gunn,  dislocation  of  thigh  on  dorsum  ilii,  636 

Hart,  dislocation  of  astragalus,  731 
Hartshorne,  reduction  of  humerus  by  mani- 
pulation (note),  566 
Head  upon  the  atlas,  521 
Hinckerman,  cervical  vertebrae,  516 
Hodge,  statistics  of  dislocations  of  the  femur, 

653 
Horner,  partial  dislocation  of  fourth  cervical 

vertebra,  514 
Howe,  reduction  of  dislocation  of  the  hip  by 

manipulation,  645 
Humerus,  dislocations  of,  540 
downwards,  540 
forwards,  566 
backwards,  572 
partial,  576 
ancient,  559 
with  fracture,  565 
congenital,  766 
Humero-scapular  dislocation,  540.     See  Hu- 

inerus. 
Hutchinson,  dislocation  of  femur,  662 

Ilio-femoral  ligament,  637 
Ilio-pubic  dislocation  of  femur,  674 
Indian  "puzzle,"  626 
Inferior  maxilla,  501 

double  dislocation,  501 

single  dislocation,  505 

congenital  dislocation,  761 
Ingalls,  reduction    of  dislocation   of  hip   by 

manipulation,  646 
Internal  derangement  of  knee-joint,  711 
Ischio-pubic  dislocation  of  femur,  668 
Ischiatic  dislocation  of  femur,  660 

Jarvis's  adjuster,  500,  558 

KiRKBRiDE,  dislocation  of  the  femur  upon 
posterior  part  of  the  body  of  the  ischium,  682 

Knee,  slipping  of  semilunar  cartilages,  711. 
See  Tibia. 

Krackowitzer,  dislocation  of  head  of  radius  in 
delivery,  579 

La  Mothe,  method  of  reducing  dislocation  of 
humerus,  655 


Lehman,  spontaneous  dislocation  of  shoulder, 

541 
Lente,  fifth  cervical  vertebra,  withfracture,  514 

fifth  cervical  vertebra,  without  fracture, 
514 

femur  directly  upwards,  680 
Levis,  reduction  of  dislocation  of  thumb,  625 
Ligamentum  patella;,  rupture  of,  702 
Long  bones,  compound  dislocation  in,  743 
Lower  jaw,  501 

simulating  luxation  of,  506 
Lumbar  vertebrse,  509 

Markoe,  on  reduction  of  dislocation  of  femur, 
647 

head  of  radius  backwards,  584  • 

femur  with  fracture,  reduced,  693 
Maxson,  dislocation  of  cervical  vertebras,  517 
Mercer,  on  partial  dislocations  of  humerus,  578 
Metacarpus,  617 

Metacarpo-phalangeal  articulation,  620 
Metatarsus,  740 
Middle  tarsal  dislocations,  737 
Moore,  on  reduction  of  dislocation  of  femur,  636 

ulna,  616 
Mussey,  dislocation  of  thumb,  624 

ancient  dislocation  of  elbow,  597 

NoRRis,  ancient  dislocations  of  the  humerus, 

563,  569 
dislocation  of  humerus    mistaken    for  a 

contusion,  569 
compound  dislocation  of  thumb,  627 

OcciPiTO-ATLOiDEAN  dislocations,  521 

Parker,   head   of  humerus   in   sub-scapular 
fossa,  568 

backwards,  572 

head  of  radius  backwards,  584 

head  of  radius  outwards,  586 

femur  into  perineum,  684 
Patella,  outwards,  696 

inwards,  699 

on  its  axis,  699 

upwards,  702 

downwards,  703 

congenital,  778 
Pathology,  general,  497 
Pelvis,  traumatic  separations,  334.     (Part  I.) 

congenital,  765 
Phalanges,  thumb  and  fingers,  620 

toes,  742 
Pope,  dislocation  of  femur  into  perineum,  085 
Predisposing  causes,  general,  494 
Prognosis,  general,  498 
Pseudo-luxations  of  inferior  maxilla,  506 
Pulleys,  500 
Purple,  dislocation  of  cervical  vertebrae,  515 

Radius,  head  dislocated  forwards,  579 

backwards,  584 

outwards,  586 

congenital,  770 
Radius  and  ulna,  dislocation  backwards,  588 

congenital,  770 

outwards,  598 

inwards,  602 

forwards,  605 
Radio-carpal  articulation,  606.     See  Car^jus. 
Radio-ulnar  articulation,  inferior,  612 
I  Rupture  of  quadriceps  femoris,  703 


I 


INDEX — DISLOCATIONS. 


789 


Reid,  reduction    of  dislocation    of  femur   by 

manipulation,  662 
Eibs  from  vertebriie,  521 
from  sternum,  523 
one  cartilage  upon  another,  524 
Rochester,  sternal  end  of  clavicle  upwards,  528 
Rudiger,  dislocation  of  dorsal  vertebras,  512 

Sacro-sciatic  dislocation  of  femur,  660 
Sanson,  third  cervical  vertebra,  515 
Scaphoid,  dislocation  of,  737 
Schuck,  dislocation  of  cervical  vertebra,  515 
Shoulder,  dislocation  of,  540.     See  Hitmems. 
Single  dislocation  of  lower  jaw,  505 
"Sixth"  dislocation  of  femur,  678 
Skey,  method  of  reducing  dislocation  of  hu- 
merus, 557 
Smith,  Nathan,  on  reduction  of  dislocation  of 
the  humerus,  554 
reduction  of  femur  by  manipulation,  643 
Smith,  H.  H.,  on  reduction  of  humerus,  568 
Spencer,  dislocation  of  cervical  vertebra,  515 
Spine,  508.     See  Vertebra. 
Squire,  T.  H.,  dislocation  of  radius  and  ulna 

inwards,  603 
Sternum,  diastasis,  167.     (Part  I.) 

congenital  dislocations,  765 
Subcoracoid  dislocation  of  humerus,  566 
Subclavicular  dislocation  of  humerus,  566 
Subcotyloid  dislocation  of  femur,  683 
Subluxation  of  the  jaw,  606 
Subglenoid  dislocation  of  the  humerus,  640 
Subpubic  dislocation  of  femur,  668 
Subspinous  dislocation  of  humerus,  572 
Swan,  dislocation  of  dorsal  vertebra,  612 
Symptomatology,  general,  495 

Tarsus,  727 

astragalus,  727 

astragalo-calcaneo-scaphoid,   735 

calcaneum,  736 

middle  tarsal  dislocation,  737 

OS  cuboides,  737 

OS  scaphoides,  737 

cuneiform  bones,  738 

congenital,  782 
Tendons,  dislocation  of,  576,  764 
Thigh,  632.     See  Femur. 
Thumb,  first  phalanx,  620 
backwards,  620 
forwards,  627 


Thumb- 
second  phalanx,  629 
Tibia,  dislocation  of  upper  end,  703 

backwards,  704 

forwards,  706 

outwards,  708 

inwards,  709 

backwards  and  outwards,  710 

congenital,  779 
lower  end,  inwards,  714 

outwards,  718 

forwards,  720 

backwards,  724 
dislocation  of  lower  end,  713 
Tibio-tarsal  luxations,  713 
Toes,  742 

congenital,  782 
Treatment,  general,  498 
Tripod  for  vertical  extension  of  femur,  660 
Trowbridge,  head  of  humerus  backwards,  572 
Twisted  rope,  extension,  600 

Ulna,  upper  end  backwards,  587 
lower  end  backwards,  612 
forwards,  276,  614 
Unilateral  luxation  of  lower  jaw,  505 

Van  Buren,   W.  H.,  dislocation  of  humerus 
backwards,  572 

reduction  of  femur  by  manipulation,  665, 
670 
Vertebra3,  508 

lumbar,  509 

dors.al,  510 

six  lower  cervical,  513 

atlas  upon  axis,  519 

head  upon  atlas,  521 

congenital  dislocations,  764 
Voluntary  dislocations,  694 

Warren,  humerus  with  fracture,  565 

Watson,  dislocation  of  patella  outwards,  698 

Wells,  dislocation  of  tibia,  711 

Windlass  for  extension,  648 

Wood,  dislocation  of  cervical  vertebrse,  517 

humerus,  with  fracture,  668 
Wrist,  606.     See  Carjnis. 

Y  ligament,  637 

Youmans,  J.,  congenital  dislocation  of  knee, 
780 


THE    END. 


i.  I 


m 


OPINIONS  OF  THE  PKESS 

ON   THE  THIRD    EDITION   OF 

HAMILTON  ON  FRACTURES  AND  DISLOCATIONS. 

The  comprehensive  treatise  of  Hamilton  is  now  recognized  on  both  sides  of  the  Atlantic  as 
one  of  the  most  valuable  text-books  on  injuries  of  bones  and  tendons. — London  Med.  Times 
and  Gazette,  Aug.  1,  1868. 

Should  be  carefully  read  by  every  student  of  surgery. — N.  Y.  Med.  Gaz.,  Oct.  17,  1868. 

In  fulness  of  detail,  simplicity  of  arrangement,  and  accuracy  of  description,  this  work 
stands  unrivalled.  So  far  as  we  know,  no  other  work  on  the  subject  in  the  English  language 
can  be  compared  with  it.  While  congratulating  our  trans -Atlantic  brethren  on  the  European 
reputation  which  Dr.  Hamilton,  along  with  many  other  American  surgeons,  has  attained,  we 
also  may  be  proud  that,  in  the  Tnother  tongzie,  a  classical  work  has  been  produced  which  need 
not  fear  comparison  with  the  standard  treatises  of  any  other  nation. — Edinburgh  Med.  Jour- 
nal Dec.  1866. 

The  credit  of  giving  to  the  profession  the  only  complete  practical  treatise  on  fractures  and 
dislocations  in  our  language  during  the  present  century,  belongs  to  the  author  of  the  work 
before  us,  a  distinguished  American  professor  of  surgery;  and  his  book  adds  one  more  to  the 
list  of  excellent  practical  works  which  have  emanated  from  his  country,  notices  of  which  have 
appeared  from  time  to  time  in  our  columns  during  the  last  few  months. — London  Lancet, 
Dee.  15,  1866. 

These  additions  make  the  work  much  more  valuable,  and  it  must  be  accepted  as  the  most 
complete  monograph  on  the  subject,  certainly  in  our  own,  if  not  even  in  any  other  language 
— American  Journal  of  Med.  Sciences,  Jan.  1867. 

This  is  one  of  those  exhaustive  books  that  students  have  to  "get  up''  with  a  view  of  being 
equal  to  anything  that  an  accomplished  and  subtle  examiner  may  inquire  about.  It  is  the 
sort  of  work  that  general  practitioners  like  to  have  on  their  bookshelves,  as  a  reference,  to 
consult  when  any  case  that  they  may  not  quite  understand,  happens  to  come  across  their  paths. 
In  America,  at  any  rate,  it  is  justly  considered  to  be  the  standard  work  on  these  points  of 
surgery.  The  fact  of  a  third  edition  of  such  a  large  work  being  called  for,  although  only 
seven  years  have  elapsed  since  the  appearance  of  the  first,  is  sufficient  evidence  of  its  being 
much  required.  It  is  used  as  a  text-book  in  many  American  schools,  and  it  speaks  well  for 
the  thorough  system  pursued  at  these  seats  of  learning,  that  a  work  which  contains  such  an 
immense  amount  of  information  should  be  used  in  this  manner. — London  Medical  Mirror, 
Feb.  1867. 

This  great  work  does  not  admit  of  criticism  on  our  part,  nor  will  the  limits  of  a  bibliogra- 
phical notice  suffice  to  give  it  the  just  measure  of  praise.  It  is  the  standard  of  medical  lite- 
rature on  this  subject.  The  mere  announcement  of  its  title  will  place  it  at  once  where  it 
deserves  to  be — in  the  front  rank  of  medical'  publications.  As  a  work,  complete  upon  the 
subject,  it  must  ever  be  one  of  reference;  it  is  replete  with  erudition,  and  a  monument  of  the 
industry  and  ability  of  the  author. — St.  Louis  Med.  Rejtorter,  Nov.  1866. 

Prof.  Hamilton,  whose  work,  ever  since  its  first  appearance,  has  taken  rank  both  at  home 
and  abroad  as  the  best  monograph  upon  the  subjects  treated  of,  in  the  English  language,  pre- 
sents us  with  the  third  edition,  in  which,  to  the  former  rich  stores  of  information,  he  adds  the 
latest  advances  in  these  branches  of  surgical  science. — Detroit  Review  of  Medicine,  Dec.  '66. 

The  work  has  met  with  such  universal  approval  that  it  is  vain  to  attempt  here  any  formal 
review  of  it.  No  medical  library  or  intelligent  practitioner  should  be  without  a  copy.  We 
cordially  recommend  it  to  the  profession  as  the  most  complete  work  to  which  the  surgeon  can 
refer  for  information  on  the  subject  of  fractures  and  dislocations. —  The  Savannah  Journal 
of  Medicine,  Nov.  1866. 

Dr.  Hamilton's  treatise  still  holds  its  place  without  a  rival  as  the  very  best  on  the  import- 
ant subjects  of  which  it  treats.  It  has  now  reached  its  third  edition  in  the  seventh  year  of  its 
existence,  evidence  enough  of  its  general  appreciation  by  the  medical  profession.  On  a  former 
occasion  we  spoke  quite  freely  of  the  merits  of  this  important  work,  and  we  need  therefore 
only  say  now,  that  the  present  edition  is  an  improvement  on  the  first  two.  It  well  sustains 
the  reputation  which  the  previous  editions  have  earned. — The  Boston  Med.  and  Surg.  Jour- 
nal, Dec.  6,  1866. 

We  have  received  a  new  (the  third)  edition  of  Prof.  Frank  H.  Hamilton's  most  admirable 
Treatise  on  Fractures  and  Dislocations.  As  a  good  practical  treatise,  this  work  has  no  equal 
in  the  English  language,  and  in  view  of  the  serious  pecuniary  responsibility  assumed  in  these 
days  by  those  who  undertake  the  treatment  of  fractures  and  dislocations,  we  do  not  see  how 
any  practitioner  can  afford  to  be  without  it  in  his  library. — Cincinnati  Journal  of  Medicine, 
Dec.  1866. 

We  regard  this  as  one  of  the  most  valuable  and  interesting  works  which  have  issued  from 
the  American  press.  —  Canada  Med.  Journal,  Nov.  1866. 

The  perfect  storehouse  of  appliances  which  are  described  and  illustrated,  renders  it  cer- 
tainly the  most  complete  work  of  the  kind  in  this  country,  and  perhaps  there  is  nothing  supe- 
rior to  it  in  any  language.  Hamilton's  treatise  is  destined  to  rank  for  a  long  while  as  the 
leading  authority  on  this  subject,  and  we  commend  it  once  more  to  our  readers  with  more 
than  usual  pleasure. — Cincinnati  La?icet  and  Observer,  Nov.  1866. 


SUEGIOAL  TEXT-BOOKS. 


GROSS'S    SURGERY. 

A  SYSTEM  OF  SUEGERY;  Pathological,  Diagnostic,  Therapeutic,  and  Ope- 
rative. By  Saiidel  D.  Gross,  M.D.,  Professor  of  Surgery  in  the  Jefferson  Medical  College 
of  Philadelphia.  Illustrated  by  upwards  of  Thirteen  Hundred  Engravings.  Fourth  edition, 
carefully  revised  and  improved.  In  two  large  and  beautifully  printed  royal  octavo  volumes 
of  2200  pages,  strongly  bound  in  leather,  with  raised  bands.     $15. 

The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students. 
Though  but  little  over  six  years  have  elapsed  since  its  first  publication,  it  has  already  reached 
its  fourth  edition,  while  the  care  of  the  author  in  its  revision  and  correction  has  kept  it  in  a 
constantly  improved  shape.  By  the  use  of  a  close,  though  very  legible  type,  an  unusually  largo 
amount  of  matter  is  condensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five 
ordinary  octavos.  This,  combinefl  with  the  most  careful  mechanical  execution,  and  its  very 
durable  binding,  renders  it  one  of  the  cheapest  works  accessible  to  the  profession.  Every  sub- 
ject properly  belonging  to  the  domain  of  surgery  is  treated  in  detail,  so  that  the  student  who 
possesses  this  work  may  be  said  to  have  in  it  a  surgical  library. 

ERICHSEN'S    SURGERY. 

THE  SCIENCE  AND  ART  OF  SURGERY  :  being  a  Treatise  on  Surgical 
Injuries,  Diseases,  and  Operations.  By  John  Erichsen,  Senior  Surgeon  to  University  Col- 
lege Hospital.  From  the  Fifth  enlarged  and  carefully  revised  London  Edition.  With 
Additions  by  John  Ashhurst,  Jr.,  M.D.,  Surgeon  to  the  Episcopal  Hospital,  ifcc.  Illustrated 
by  over  Six  Hundred  Engravings  on  wood.  In  one  very  large  and  beautifully  printed  impe- 
rial octavo  volume,  containing  over  twelve  hundred  closely  printed  pages.  Cloth,  $7  50 ; 
leather,  raised  bands,  $S  50.     (Lntely  Puhlished.) 

DRUITT'S    SURGERY. 

THE   PRINCIPLES   AND    PRACTICE   OF    MODERN    SURGERY.     By 

Robert  Druitt,  M.R.C.S.,  &c.  A  new  and  revised  American,  from  the  eighth  enlarged 
and  improved  London  Edition.  Illustrated  with  Four  Hundred  and  Thirty-two  Wood  En- 
gravings. In  one  very  handsome  octavo  volume,  of  nearly  seven  hundred  large  and  closely 
printed  pages.     Extra  cloth,  §i;  leather,  $5. 

PRINCIPLES  OF  SURGERY.     By  James  Miller,  late  Professor  of  Surgery 

in  the  University  of  Edinburgh,  &o.  Fourth  American,  from  the  third  and  revised  Edin- 
burgh Edition.  In  one  large  and  very  beautiful  volume  of  seven  hundred  pages,  with  Two 
Hundred  and  Forty  Illustrations  on  wood.     Extra  cloth,  $3  75. 

Si/  the  satne  Author. 

THE  PRACTICE  OF  SURGERY.    Fourth  American,  from  the  last  Edinburgh 

Edition.  Revised  by  the  American  Editor.  Illustrated  by  Three  Hundred  and  Sixty-four 
Engravings  on  wood.    In  one  large  octavo  volume  of  nearly  700  pages.    Extra  cloth,  $3  7o. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.    By  William  Pir- 

RiE,  F.R.S.E.,  Professor  of  Surgery  in  the  University  of  Aberdeen.  Edited  by  John  Xeill, 
M.D.,  Professor  of  Surgery  in  the  Pennsylvania  Medical  College,  Surgeon  to  the  Pennsylva- 
nia Hospital,  (fee.  In  one  very  handsome  octavo  volume  of  780  pages,  with  Three  Hundred 
and  Sixteen  Illustrations.     Extra  cloth,  $'i  75. 

ON  BANDAGING  AND  OTHER  OPERATIONS  OF  MINOR  SURGERY. 

By  F.  W.  Sargent,  M.D.  New  Edition,  with  an  additional  chapter  on  Military  Surgery. 
One  handsome  royal  12mo.  volume,  of  nearly  400  pages,  with  One  Hundred  and  Eighty-four 
AVood-cuts.     Extra  cloth,  $1  75. 

MECHANICAL  THERAPEUTICS:  a  Practical  Treatise  on  Surgical  Appa- 
ratus, Appliances,  and  Elementary  Operations :  embracing  Minor  Surgery,  Bandaging, 
Orthopraxy,  and  the  Treatment  of  Fractures  and  Dislocations.  By  Philip  S.  Wales,  M.D., 
Surgeon  U.S.N.  With  Six  Hundred  and  Forty-two  Illustrations  on  wood.  In  one  large 
and  handsome  octavo  volume  of  about  700  pages.     Extra  cloth,  §5  75;  leather,  $6  75. 


THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.  For  the  use  of  Stu- 
dents and  Practitioners.  By  John  Ashhurst,  Jr.,  M.D.,  Surgeon  to  the  Episcopal  Hospital, 
Philadelphia.  In  one  very  handsome  octavo  volume,  with  several  hundred  Illustrations. 
(A'^early  Ready.) 

THE  PRACTICE  OF  SURGERY.  By  Thomas  Bryant,  F.R.C.S.  A  Manual. 
With  numerous  Engravings  on  wood.     In  one  handsome  octavo  volume. 


HENRY  C.  LEA,  Philadelphia. 


(late  lea  k  blanchard's) 

O  F 

MEDICAL  AND  SURGICAL  PUBLICATIONS. 


In  asking  the  attention  of  the  profession  to  tlie  works  contained  in  the  followiu(T 
pages,  the  publisher  would  state  that  no  pains  are  spared  to  secure  a  continuance  of 
the  confidence  earned  for  the  publications  of  the  house  by  their  careful  selection  and 
accuracy  and  finish  of  execution. 

The  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  booksellers 
throughout  the  United  States,  who  can  readily  procure  for  their  customers  any  works 
not  kept  in  stock/  Where  access  to  bookstores  is  not  convenient,  books  will  be  sent 
by  mail  post-paid  on  receipt  of  the  price,  but  no  risks  are  assumed  either  on  the 
money  or  the  books,  and  no  publications  but  my  own  are  supplied.  Gentlemen  will 
therefore  in  most  cases  find  it  more  convenient  to  deal  with  the  nearest  bookseller. 

An  Illustrated  Catalogue,  of  64  octavo  pages,  handsomely  printed,  will  be  for- 
warded by  mail,  postpaid,  on  receipt  of  ten  cents. 

HENRY  C.  LEA. 

Nos.  706  and  708  Sanson  St.,  Philadelphia,  April,  1873. 


ADDITIONAL  INDUCEMENT  FOR  SUBSCRIBERS  TO 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES. 


THREE  MEDICAL  JOUElf ALS,  containing  over  2000  LAEGE  PAGES, 

Free  of  Postage,  for  SIX  DOLLARS  Per  Annum. 

TERMS   FOR  1873: 

The  American  Journal  op  the  Medical  Sciences,  and  \  Five  Dollars  per  annum, 
TheMedicalNews  and  Library,  both  free  of  postage,      j  in  advance.    ' 

OR., 

The  American  Journal  of  the  Medical  Sciences,  published  quar-")  o-     -pv  ,< 

terly  (ll.oO  pages  per  annum),  with  j  ^^^  AJoIlara 

The  Medical  News  and  Library,  monthly  (384  pp.  per  annum),  and  )■  per  annum 

in  advance. 


The  Half-Yearly  Abstract  of  the  Medical  Sciences,  published 
Feb.  and  August  ((iOO  pages  per  annum),  all  free  of  postage. 


SEPARATE  SUBSCRIPTIONS  TO 

The  American  Journal  of  the  Medical  Sciences,  subject  to  postage  when  not  paid 

for  in  advance,  Five  Dollars. 
The  Medical  News  and  Library,  free  of  postage,  in  advance.  One  Dollar. 
The  Half-Ykarly  Abstract,  Two  Dollars  and  a  Half  per  annum  in  advance.     Single 

numbers  One  Dollar  and  a  Half. 

It  is  manifest  that  only  a  very  wide  circulation  can  enable  so  vast  an  amount  of 
valuable  practical  matter  to  be  supplied  at  a  price  so  unprecedentedly  low.  'I'he  pub- 
lisher, therefore,  has  much  gratification  in  stating  that  the  rapid  and  steady  increase 
in  the  subscription  list  promises  to  render  the  enterprise  a  permanent  one,  and  it  is 
with  especial  pleasure  that  he  acknowledges  the  valuable  assistance  spontaneously 
rendered  by  so  many  of  the  old  subscribers  to  the  "  Journal,"  who  have  kindly  made 


(For  "  American  Chemist,"  see  p.  11.) 
(For  "  Obstetricai,  Journal,"  see  p.  22) 


2         Henry  C.  Lea's  Publications — (Am.  Journ.  Med.  Sciences). 

known  amon?  their  friends  the  advantages  thus  offered  and  have  induced  them  to 
sul.scribe.  Relying  upon  a  continuance  of  these  friendly  exertions,  he  hopes  to  be 
'able  to  maintain  the  unexampled  rates  at  which  these  works  are  now  supplied,  and  to 
succeed  in  his  endeavor  to  place  upon  the  table  of  every  reading  practitioner  in  the 
United  States  a  monthly,  a  quarterly,  and  a  half-yearly  periodical  at  the  comparatively 
triflino-  cost  of  Six  Dollars  per  avmim. 

Thele  periodicals  are  universally  known  for  their  high  professional  standing  in  their 
several  spheres. 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES, 

Edited  by  ISAAC  HAYS,  M.  D., 

is  published  Quarterly,  on  the  first  of  January,  April,  July,  and  October.  Each 
number  contains  nearly  three  hundred  large  octavo  pages,  appropriately  illustrated, 
wherever  necessary.  It  has  now  been  issued  regularly  for  nearly  fifty  years,  during 
almost  the  whole  of  which  time  it  has  been  under  the  control  of  the  present  editor. 
Throughout  this  long  period,  it  has  maintained  its  position  in  the  highest  rank  of 
medical  periodicals  both  at  home  and  abroad,  and  has  received  the  cordial  support  of 
the  entire  profession  in  this  country.  Among  its  Collaborators  will  be  found  a  large 
numter  of  the  most  distinguished  names  of  the  profession  in  every  section  of  the 
United  States,  rendering  the  department  devoted  to 

ORiaiNAL     COMMTJNICATIONS 

full  of  varied  and  important  matter,  of  great  interest  to  all  practitioners.  Thus,  during 
1872  articles  have  appeared  in  its  pages  from  nearly  one  hundred  gentlemen  of  the 
highest  standing  in  the  profession  throughout  the  United  States.* 

Following  this  is  the  "Review  Department,"  containing  extended  and  impartial 
review's  of  all  important  new  works,  together  with  numerous  elaborate  "Analytical 
AND  Bibliographical  Notices"  of  nearly  all  the  medical  publications  of  the  day. 

This  is  followed  by  the  "Quarterly  Summary  of  Improvements  and  Discoveries 
IN  THE  Medical  Sciences,"  classified  and  arranged  under  different  heads,  presenting 
a  very  complete  digest  of  all  that  is  new  and  interesting  to  the  physician,  abroad  as 
well  as  at  home. 

Thus,  during  the  year  1872,  the  "Journal"  furnished  to  its  subscribers  Eighty-four 
Orioinal  Communications,  Out  Hundred  and  Twenty-nine  Reviews  and  Bibliograph- 
icarNotices.  and  Three  Hundred  and  seven  articles  in  the  Quarterly  Summaries  mak- 
ing a  total  of  about  Five  Hundred  articles  emanating  from  the  best  professional 
minds  in  America  and  Europe. 

That  the  efforts  thus  made  to  maintain  the  high  reputation  of  the  "  Journal"  are 
successful,  is  shown  by  the  position  accorded  to  it  in  both  America  and  P^urope  as  a 
national  exponent  of  medical  progress  : — 

Dr.  Hays  keeps  bis  great  American,  Qiinrterly,  in  matter  it  contains,  and  has  established  for  itself  » 
which  he  is  now  assisted  by  Dr.  Minis  Hays,  at  the  reputation  in  every  country  where  medicine  is  cnl- 
head  of  his  country's  medical  periodicals. — Dublin  tivated  as  a  science. — Brit,  and  Fi>r.  Med.-Chirurg. 
Medical  Press  and  Circular,  March  8,  1871. 

Of  English  periodicals  the  Lnncft,  and  of  American 
the  Am.  Journal  of  the  Medical  Sciences,  are  to  be 
regarded  as  necessities  to  the  reading  practitioner. — 
A'   Y.  Medical  Gazette,  Jan.  7,  1871. 

The  American  Journal  of  the  Medical  Sciences! 
yields  to  none  in  the  amount  of  original  and  borrowed 

The  subscription  price  of  the  "American  Journal  of  the  Medical  Sciences"  has 
never  been  raised,  during  its  long  career.  It  is  still  Five  Dollars  per  annum  ;  and 
when  paid  for  in  advance,  the  subscriber  receives  in  addition  the  "Medical  News  and 
Library,"  making  in  all  about  1500  large  octavo  pages  per  annum,  free  of  postage. 

II. 

THE  MEDICAL  NEWS  AND  LIBRARY 

is  a  monthly  periodical  of  Thirty-two  large  octavo  pages,  making  384  pages  p?r 
annum.  Its  "News  Department"  presents  the  current  information  of  the  day,  with 
Clinical  Lectures  and  Hospital  Gleanings;  while  the  "Library  Department"  is  de- 
voted to  publishing  standard  works  on  the  various  branches  of  medical  science,  paged 
separately,  so  that  they  can  be  removed  and  bound  on  completion.  In  this  manner 
subscribers  have  received,  without  expense,  such  works  as  "  Watson's  Practice," 
"Todd  and  Bowman's  Physiology,"  "West  on  Children,"  "Malgaigne's  Surgery," 
<fec.  <fec.     And  with  January  1873  will  be  commenced  the  publication  of  Dr.  McCall 

*  Cimimunications  are  invited  from  gentlemen  in  all  parts  of  the  country.  £labora(«  articl«8  inserted 
by  the  Editor  are  paid  for  by  the  Pablisuer. 


Review,  April,  1871. 

Cue  of  the  best  of  its  kind. — London  Lancet,  Ang. 
20,  1870. 

Almost  the  only  one  that  circulates  everywhere, 
all  over  the  Union  and  in  Europe. — London  Mtdical 
Times,  Sept.  5,  1S68. 


Henry  C.  Lea's  Publications — (Am.  Journ.  Med.  Sciences).        3 

Anderson's  new  work  "On  the  Treatment  of  Diseases  of  the  Skin,  with  an  Ana- 
lysis OF  Er-EVEN  Thousand  Consecutive  Cases." 

As  stated  above,  the  subscription  price  of  the  "Medical  News  and  Library"  ia 
One  Dollar  per  annum  in  advance ;  and  it  is  furnished  without  charge  to  all  advance 
paying  subscribers  to  the  "American  Journal  of  the  Medical  Sciences." 

III. 

THE  HALF-YEARLY  ABSTRACT  OF  THE  MEDICAL  SCIENCES 

is  issued  in  half-yearly  volumes,  which  will  be  delivered  to  subscribers  about  the  first 
of  February,  and  first  of  August.  Each  volume  contains  about  300  closely  printed 
octavo  pages,  making  about  six  hundred  pages  per  annum. 

"Banking's  Abstract"  has  now  been  published  in  England  regularly  for  more  than 
twenty  years,  and  has  acquired  the  highest  reputation  for  the  ability  and  industry 
with  which  the  essence  of  medical  literature  is  condensed  into  its  pages.  It  pur- 
ports to  be  "-A  Digest  of  British  and  Continental  Medicine,  and  of  the  Progress  of 
Medicine  and  the  Collateral  Sciences,"  and  it  is  even  more  than  this,  for  America  is 
largely  represented  in  its  pages.  It  draws  its  material  not  only  from  all  the  leading 
American,  British,  and  Continental  journals,  but  also  from  the  medical  works  and 
treatises  issued  during  the  preceding  six  months,  thus  giving  a  complete  digest  of 
medical  progress.  Each  article  is  carefully  condensed,  so  as  to  present  its  substance 
in  the  smallest  possible  compass,  thus  affording  space  for  the  very  large  amount  of  infor- 
mation laid  before  its  readers.     The  volumes  of  1872,  for  instance,  have  contained 

SIXTY-FOUR  articles  ON  GENERAL  QUESTIONS  IN  MEDICINE. 

NINETY-SIX  ARTICLES  ON  SPECIAL  QUESTIONS  IN  MEDICINE. 

TWELVE  ARTICLES  ON  FORENSIC  MEDICINE. 

NrXETYTHREE  ARTICLES  ON  THERAPEUTICS. 

FORTY-TWO  ARTICLES  ON  GENERAL  QUESTIONS  IN  SURGERY. 

ONE  HUNDRED   AND  THIRTY  THREE  ARTICLES  ON  SPECIAL  QUESTIONS  IN  SURGERY 

EIGHTY  ARTICLES  ON  MIDWIFERY  AND  DISEASES  OF  WOMEN  AND  CHILDREN 

EIGHTEEN  ARTICLES  IN  APPENDIX. 

Making  in  all  nearly  five  hundred  and  fifty  articles  in  a  single  year.  Each  volume 
moreover,  is  systematically  arranged,  with  an  elaborate  Table  of  Contents  and  a  very 
full  Index,  thus  facilitating  the  researches  of  the  reader  in  pursuit  of  particular  sub- 
jects, and  enabling  him  to  refer  without  loss  of  time  to  the  vast  amount  of  information 
contained  in  its  pages. 

The  subscription  price  of  the  "Abstract,"  mailed  free  of  postage,  is  Two 
Dollars  and  a  Half  per  annum,  payable  in  advance.     Single  volumes,  $1  50  each. 

As  stated  above,  however,  it  will  be  supplied  in  conjunction  with  the  "AiMerican 
Journal  of  the  Medical  Sciences"  and  the  "  Medical  News  and  Library  "  the 
whole /ree  of  postage,  for  Six  Dollars  per  annum  in  advance. 

For  this  small  sum  the  subscriber  will  therefore  receive  three  periodicals  costing 
separately  Eight  Dollars  and  a  Half,  each  of  them  enjoying  the  highest  reputation  in 
its  class,  containing  in  all  over  two  thousand  pages  of  the  choicest  reading,  and  pre- 
senting a  complete  view  of  medical  progress  throughout  both  hemispheres. 

In  this  effort  to  bring  so  large  an  amount  of  practical  information  within  the  reach 
of  every  member  of  the  profession,  the  publisher  confidently  anticipates  the  friendly 
aid  of  all  who  are  interested  in  the  dissemination  of  sound  medical  literature.  He 
trusts,  especially,  that  the  subscribers  to  the  "American  Medical  Journal"  will  call 
the  attention  of  their  acquaintances  to  the  advantages  thus  offered,  and  that  he  will 
be  sustained  in  the  endeavor  to  permanently  establish  medical  periodical  literature  on 
a  footing  of  cheapness  never  heretofore  attempted. 

niEMIUM  FOR  NEW  SUBSCRIBERS. 

Any  gentleman  who  will  remit  the  amount  for  two  subscriptions  for  187;>,  one  of 
which  must  be  for  a  new  subscriber,  will  receive  as  a  premium,  free  by  mail,  a  copy  yf 
the  new  edition  of  Tanner's  Clinical  Manual,  for  advertisement  of  wliicli  see  p.  5, 
or  of  Chambers'  Rkstorative  Medicine  (see  p.  17),  or  West  on  Nervous  Disorders 
OF  Children  (see  p.  21). 

%*  (ientlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  do 
well  to  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of 
complete  sets  for  the  year  1873,  as  the  constant  increase  in  the  subscription  list  aliaost 
always  exhausts  the  quantity  printed  shortly  after  publication. 

I^°  The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn 
to  the  order  ol  the  undersigned.  Where  these  are  not  accessible,  remittances  for  the 
"Journal"  may  be  made  at  the  risk  of  the  publisher,  by  forwarding  in  REoirixKBKD 
letters,     j^ddress, 

HENRY  C.  LEA, 
Nos.  706  and  708  Sansom  Sr.,  Philadelphia,  Pa. 


Henry  C.  Lea's  Publications — {Dictionaries). 


fiUNGLISON  [ROBLEY],  M.D., 

'^  Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

MEDICAL   LEXICON;   A  Dictionary   of  Medical  Science:    Con- 
taining a  concife  eKplanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygienp,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence,  and  Dentistry.     Notices  of  Climate  and  of  Mineral  Waters;   Formulae  for 
Officinal,  Empirical,  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  of 
the  Terms,  and  the  French  and  other  Synonymes;  so  as  to  constitute  a  French  as  well  as 
English  Medical  Lexicon.    Thoroughly  Revised,  and  very  greatly  Modified  and  Augmented. 
In  one  very  large  and  handsome  royal  octavo  volume  of  1048  double-columned  pages,  in 
small  type;  strongly  done  up  in  extra  cloth,  $(5  00;  leather,  raised  bands,  $ti  76. 
The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  under  each,  a  condensed  view  of  its  various  medical  relation?, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.     Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  position 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken.     The  mechanical  exe- 
cution of  this  edition  will  be  found  greatly  superior  to  that  of  previous  impressions.    By  enlarging 
the  size  of  the  volume  to  a  royal  octavo,  and  by  the  employment  of  a  small  but  clear  type,  on 
extra  fine  paper,  the  additions  have  been  incorporated  without  materially  increasing  the  bulk  of 
the  volume,  and  the  matter  of  two  or  three  ordinary  octavos  has  been  compressed  into  the  space 
of  one  not  unhandy  for  consultation  and  reference. 

It  is  undoubtedly  the  most  complete  and  usefnl 
medical  dictionary  hitherto  published  in  this  country. 
— Chicago  Med.  Examiner,  February,  1S6.5. 

What  we  take  to  be  decidedly  the  best  medical  dic- 


It  would  be  a  work  of  supererogation  to  bestow  a 
word  of  praise  upon  this  Lexicon.  We  can  only 
wonder  at  the  labor  expended,  for  whenever  we  refer 
to  its  pages  for  information  we  are  seldom  disap- 
pointed in  finding  all  we  desire,  whether  it  be  in  ac- 
centuation, etymology,  or  definition  of  terms. — New 
York  MedicalJournal ,  November,  1865. 

It  would  be  mere  waste  of  words  in  us  to  express 
our  admiration  of  a  work  which  is  so  universally 
and  deservedly  appreciated.  The  most  admirable 
work  of  its  kind  in  the  English  language.  As  a  book 
of  reference  it  is  invaluable  to  the  medical  practi- 
tioner, and  in  every  instance  thai  we  have  turned 
over  its  pages  for  information  we  have  been  charmed 
by  the  clearness  of  language  and  the  accuracy  of 
detail  with  which  each  abounds.  We  can  most  cor- 
dially and  confidently  commend  it  to  our  readers. — 
Glasgow  Medical  Journal,  January,  1866. 

A  work  to  which  there  is  no  equal  in  the  English 
language. — Edinburgh  Medical  Journal. 

It  is  something  more  than  a  dictionary,  and  some- 
thing less  than  an  eucyclopfedia.  This  edition  of  the 
well-known  work  is  a  great  improvement  on  its  pre- 
decessors. The  book  is  one  of  the  very  few  of  which 
it  may  be  said  with  truth  that  every  medical  man 
should  possess  it. — London  Medical  Times,  Aug.  26, 
1865. 

Few  works  of  the  class  exhibit  a  grander  monument 
of  patient  research  and  of  scientific  lore.  The  extent 
of  the  sale  of  this  lexicon  is  sufficient  to  testify  to  its 
usefulness,  and  to  the  greav  service  conferred  by  l)r. 
Robley  Dunglison  on  the  profession,  and  indeed  on 
athers,  by  its  issue. — London  Lancet,  May  13,  1865. 

The  old  edition,  which  is  now  superseded  by  the 
new,  has  been  universally  looked  upon  by  the  medi- 
cal profession  as  a  work  of  immense  research  and 
great  value.  The  new  has  increased  usefulness;  for 
medicine,  in  all  its  branches,  has  been  making  such 
progress  that  many  uew  terms  and  subjects  have  re- 
cently been  introduced  :  All  of  which  may  be  found 
fully  defined  in  the  present  edition.  We  know  of  no 
other  dictionary  in  the  English  language  that  can 
bear  a  comparison  with  it  in  point  of  completeness  of 
subjects  and  accuracy  of  statement. — iV.  Y.  Drug- 
gists^ Circular,  1865. 

For  many  years  Dunglison's  Dictionary  has  been 
the  standard  book  of  reference  with  most  practition- 
ers in  this  country,  and  we  can  certainly  commend 
this  work  to  the  renewed  confidence  and  regard  of 
our  readers. — Cincinnati  Lancet,  April,  1865. 


tionary  in  the  English  language.  The  present  edition 
is  brought  fully  up  to  the  advanced  state  of  science. 
For  many  a  long  year  "Dunglison"  has  been  at  our 
elbow,  a  constant  companion  and  friend,  and  we 
greet  him  in  his  replenished  and  improved  form  with 
especial  satisfaction. — Pacific  Med.  and  Surg.  Jour- 
nal, June  27,  1865. 

This  is,  perhaps,  the  book  of  all  others  which  the 
physician  or  surgeon  should  have  on  his  shelves.  It 
is  more  needed  at  ihe  present  day  than  a  few  years 
back.  —  Canada  Med.  Journal,  July,  1865. 

It  deservedly  stands  at  the  head,  and  cannot  be 
surpassed  in  excellence. — Buffalo  Med.  and  Surg. 
Journal,  April,  1865. 

We  can  sincerely  commend  Dr.  Dunglison's  work 
as  most  thorough,  scientific,  and  accurate.  We  have 
tested  it  by  searching  its  pages  for  new  terms,  which 
have  abounded  so  much  of  late  in  medical  nomen- 
clature, and  our  search  has  been  successful  in  every 
instance.  We  have  been  particularly  struck  with  the 
fulness  of  the  synonymy  and  the  accuracy  of  the  de- 
rivation of  words.  It  is  as  necessary  a  work  to  every 
enlightened  physician  as  Worcester's  English  Dic- 
tionary is  to  every  one  who  would  keep  up  his  knowl- 
edge of  the  English  tongue  to  the  standard  of  the 
present  day.  It  is,  to  our  mind,  the  most  complete 
work  of  the  kind  with  which  we  are  acquainted. — 
Boston  Med.  and  Stirg.  Journal,  June  22,  1865. 

We  are  free  to  confess  that  we  know  of  no  medical 
dirtiouary  more  complete;  no  one  better,  if  so  well 
adapted  for  the  use  of  the  student;  no  one  that  may 
be  consulted  with  more  satisfaction  by  the  medical 
practitioner. — Am.  Jour.  Med.  Sciences,  April,  1865. 

The  value  of  the  present  edition  has  beengreatly 
enhanced  by  the  introduction  of  new  subjects  and 
terms,  and  a  more  complete  etymology  auu  atceutna- 
tion,  which  renders  the  work  not  only  satisfactory 
and  desirable,  but  indispensable  to  the  physician. — 
Chicago  Med.  Journal,  April,  1865. 

No  intelligent  member  of  the  pr,)fes8ion  can  or  will 
be  without  it. — St.  Louis  Med.  and  Surg.  Journal. 
April,  1865. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent  of 
references. — London  Medical  Gazette. 


TJOBLYN  {RICHARD  D.), 


ID. 


A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  collateral  SCIENCES.  Revised,  with  numerout  additions,  by  Isaac  Hays, 
M.D.,  Editor  of  the  "American  Journal  of  the  Medical  Sciences."  In  one  large  royal 
12mo.  volume  of  over  500  double-columned  pages  ;  extra  cloth,  $1   50  ;  leather,  <^2  00. 

It  is  the  best  book  of  definitions  we  have,  and  ought  aiways  to  be  upon  tn©  atndent'a  cable. — Suultn:rn 
lied,  and  Surg.  Journal 


Henry  C  Lea's  Publications — {ManuaU). 


l^EILL  {JOHN),  M.D.,    and     ^MITH  [FRANCIS  G.),  M.D., 


O 


Prof,  of  the  InstittUes  of  Medicine  in  the  Univ.  of  Penna. 

A^   ANALYTICAL    COMPENDIUM   OF   THE   YAKIOUS 

BRANCHES  OF  MEDICAL  SCIENCE  ;  for  the  Use  and  Examination  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12m(>. 
volume,  of  about  one  thousand  pages,  with  374  wood  cuts,  extra  cloth,  $4 ;  strongly  bound 
in  leather,  with  raised  bands,  $4  75. 


The  Compend  of  Drs.  Neill  and  Smith  is  incompara- 
bly the  most  valuable  work  of  its  class  ever  published 
In  this  country.  Attempts  have  been  made  in  various 
quarters  to  squeeze  Anatomy,  Physiology,  Surgery, 
the  Practice  of  Medicine,  Obstetrics,  Materia  Medica, 
and  Chemistry  info  a  single  manual;  but  the  opera- 
tion has  signally  failed  in  the  hands  of  all  up  to  the 
advent  of  "  Neill  and  Smith's"  volume,  which  is  quite 
a  miracle  of  success.  The  outlines  of  the  whole  are 
admirably  drawn  and  illustrated,  and  the  authors 
are  eminently  entitled  to  the  grateful  consideration 
of  the  student  of  every  class. — N.  0.  Med.  and  Surg. 
Journal. 

There  are  bnt  few  students  or  practitioners  of  me- 
dicine unacquainted  with  the  former  editions  of  this 
unassuming  though  highly  instructive  work.  The 
whole  science  of  medicine  appears  to  have  been  sifted, 
a,s  the  gold-bearing  sands  of  El  Dorado,  and  the  pre- 


cious facts  treasured  up  In  this  little  volume.  Acoro- 
plete  portable  library  so  condensed  that  the  student 
may  make  it  his  constant  pocket  companion. —  West- 
ern Lancet. 

In  the  rapid  course  of  lectures,  where  work  for  the 
students  is  heavy,  and  review  necessary  for  an  exa- 
mination, a  compend  is  not  only  valuable,  but  it  is 
almost  a  ■'iine'qua  non.  The  one  before  us  is,  in  moist 
of  the  divisions,  the  most  unexceptionable  of  all  books 
of  the  kind  that  we  know  of.  Of  course  it  is  useless 
for  us  to  recommend  it  to  all  last  course  students,  but 
there  is  a  class  to  whom  we  very  sincerely  commend 
this  cheap  book  as  worth  its  weight  in  silver — that 
class  is  the  graduates  in  medicine  of  more  than  ten 
years'  standing,  who  have  not  studied  mediciue 
since.  They  will  perhaps  find  out  from  it  that  the 
science  is  not  exactly  now  what  it  was  when  they 
left  it  off. — The  Stethoscope, 


TTARTSHORNE  [HENRY],  M.  D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A    CONSPECTUS    OF    THE    MEDICAL    SCIENCES;    containing 

Handbooks  on   Anatomy,    Physiology,  Chemistry,  Materia   Medica,    Practical   Medicine, 
Surgery,  and  Obstetrics.     In  one  large  royal  12rao.  volume  of  1000  closely  printed  pages, 
with  over  300  illustrations  on  wood,  extra  cloth,  $4  50  ;    leather,  raised  bands,  $5  25. 
{Lately  PuhUshed.) 
The  ability  of  the  author,  and  his  practical  skill  ih  condensation,  give  assurance  that  this 
work  will  prove  valuable  not  only  to  the  student  preparing  for  examination,  but  also  to  the  prac- 
titioner desirous  of  obtaining  within  a  moderate  compass,  a  view  of  the  existing  condition  of  the 
various  departments  of  science  connected  with  medicine. 

This  work  is  a  remarkably  complete  one  in  its  way, 
and  comes  nearer  to  our  idea  of  what  a  Conspectus 
aho^ild  be  than  any  we  have  yet  seen.     Prof.  Harts- 


horne,  with  a  commendable  forethought,  intrusted 
the  preparation  of  many  of  the  chapters  on  special 
subjects  to  experts,  reserving  only  anatomy,  physio- 
logy, and  practice  of  medicine  to  himself.  As  a  result 
we  have  every  department  worked  up  to  the  latest 
date  and  in  a  refreshingly  concise  and  lucid  manner. 
There  are  an  immense  amount  of  illustrations  scat- 
tered throughout  the  work,  and  although  they  have 
often  been  seen  before  in  the  various  works  upon  gen- 
eral and  special  subjects,  yet  they  will  be  none  the 


less  valuable  to  the  beginner.  Every  medical  student 
who  desires  a  reliable  refresher  to  his  memory  whea 
the  pressure  of  lectures  and  other  college  work  crowds 
to  prevent  him  from  having  an  opportunity  to  drink 
deeper  in  the  larger  works,  will  find  this  one  of  the 
greatest  utility.  It  is  thoroughly  trustworthy  from 
beginning  to  end;  and  as  we  have  before  intimated, 
a  remarkably  truthful  outline  sketch  of  the  present 
slate  of  medical  science.  We  could  hardly  expect  it 
should  be  otherwise,  however,  under  the  charge  of 
such  a  thorough  medical  scholar  as  the  author  has 
already  proved  himself  to  be. — N.  York  Med.  Record, 
March  1.5,  1869. 


T  UDLOW  [J.L.),  M.D. 
A   MANUAL   OF   EXAMINATIONS   upon   Anatomy,   Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations.  In  one  handsome  royal 
12mo.  volume  of  816  large  pages,  extra  cloth,  $3  25;  leather,  $3  75. 
The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
able for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 

mANNER  [THOMAS  HA  WKES),  M.  D.,  ^c. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 

NOSIS.     Third  American  from  the  Second  London  Edition.     Revised  and  Enlarged  hy 

Tilbury  Fox,  M   D.,  Physician  to  the  Skin  Department  in  University  College  Hospital, 

&c.    In  one  neat  volume  small  12mo.,  of  about  375  pages,  extra  cloth.   $150.    (Jiisl  Issued.) 

***  By  reference  to  the  "  Prospectus  of  Journal"  on  page  3,  it  will  be  seen  that  this  work  is 

offered  as  a  premium  for  procuring  new  subscribers  to  the  "American  Journal  of  the  Medicai. 

Sciences." 


Taken  as  a  whole,  it  is  the  most  compact  vade  me- 
cum  for  the  use  of  the  advanced  student  and  junior 
practitioner  with  which  we  are  acquainted. — Boston 
Med.  and  Surg.  Journal,  Sept.  22,  1S70. 

It  contains  so  much  that  is  valuable,  presented  in 
so  attractive  a  form,  that  it  can  hardly  be  spared 
even  in  the  presence  of  more  full  and  complete  works. 
The  additions  made  to  the  volume  by  Mr.  Fox  very 
materially  enhance  its  value,  and  almost  make  it  a 
new  work.  Its  convenient  size  makes  it  a  valuable 
companion  to  the  country  practitioner,  and  if  con- 
stantly carried  by  him,  would  often  render  him  good 
service,  and  relieve  many  a  doubt  and  perplexity. — 
Leavenworth  Med.  Herald,  July,  1870. 


The  objections  commonly,  and  justly,  urged  against 
the  general  run  of  "compeuds,"  "couspectuses,''  and 
other  aids  to  indolence,  are  not  applicable  to  this  little 
volume,  which  contains  in  concise  phrase  just  thofe 
practical  details  that  are  of  most  use  in  daily  diag- 
nosis, but  which  the  young  practitioner  finds  it  diBl- 
cult  to  carry  always  in  his  memory  without  some 
quickly  accessible  means  of  reference.  Altogether, 
the  book  is  oue  which  we  can  heartily  commend  lo 
those  who  have  not  opportunity  for  extensive  read- 
ing, or  who,  having  read  much,  still  wish  an  occa- 
sional practical  reminder. — iV'.  T.  Med.  Gazette,  Not. 
10,  1S70. 


6  Henry  C.  Lea's  Publications — (Anatoviy). 


fyRAV  (HENRY),  F.  R.  S., 

^  Lecturer  on  Anatomy  at  St.  George's  Hospital,  London. 

ANATOMY,    DESCRIPTIVE    AND    SURGICAL.      The  Drawinp:s  by 

H.  V.  Carter,  M.  D.,  late  Demonstrator  on  Anatomy  at  St.  George's  Hospital ;  the  Dissec- 
tions jointly  by  the  Author  and  Dr.  Carter.     A  new  American,  from  ihe  fifth  enlarged 
and  improved  London  edition.     In  one  magnificent  imperial  octavo  volume,  of  nearly  900 
pages,  with  465  large  and  elaborate  engravings  on  wood.     Price  in  extra  cloth,  $6  00  ; 
leather,  raised  bands,  $7  00.      {J»st  Issued.) 
The  a'athor  has  endeavored  in  this  work  to  cover  a  more  extended  range  of  subjects  than  is  cus- 
tomary in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thus  rendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.     The  en- 
gravings form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
fio^ures  of  reference,  with  descriptions  at  the  foot.    They  thus  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea,  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room;  while  combining,  as  it  does,  a  complete  Atlns  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  oflaces,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medicjil  education. 

Notwithstanding  the  enlargement  of  this  edition,  it  has  been  kept  at  its  former  very  moderate 
price,  rendering  it  one  of  the  cheapest  works  now  before  the  profession. 


The  illustrations  are  lieaulifully  expciited,  and  ren- 


der this  work  an  indispensable  adjunct  to  tlie  library    peared,  we  have  had  nuicli    pleasure  in  expressing 


of  the  surgeon.  This  remark  applies  with  great  foice 
to  those  surgeons  practising  at  a  distance  froin  our 
large  cities,  as  the  opportunity  of  refreshing  their 
memory  by  actual  dissection  is  not  always  attain- 
able—C(7«niia  3Ied  Journal,  Aug.  1S70. 
The  work  is  too  well  known  and  appreciated  by  the 


From  time  to  time,  as  successive  editions  have  ap- 


the  g>?ueral  judgment  of  the  wonderful  excellence  of 
Gray's  Anatomy. — Cincinnati  Laiicet,  July,  1870. 

Altogether,  it  is  unquestionably  the  most  complete 
and  serviceable  textbook  in  anatomy  that  has  ever 
been  presented  to  the  student,  and  forms  a  striking 
contrast  to  Ihe  dry  and  perplexing  volumes  on  the 


profession  to  need  any  comment.  No  medical  man  i  same  subject  through  which  their  predecessors  strng- 
cau  afford  to  be  without  it,  if  its  only  merit  Were  to  ^  gled  in  days  gone  by. — N.  Y.  MeA.  Record,  June  15, 
serve  as  a  reminder  of  that  which  so  soon  becomes  |  1870. 

forgotten,  when  not  called  into  frequent  use,  viz  the  I  t„  commend  Gray's  Anatomy  to  the  medical  pro- 
relations  and  names  of  the  complex  orgajiism  of  the  [  fession  is  almost  as  much  a  work  of  supererogation 
human  body.  The  present  edition  is  much  improved.  ^  as  it  would  be  to  give  a  favorable  notice  of  the  Bible 
—Oaliforma  Med.  Gazette,  July,  1870.  [  j^  j^e  religious  press.     To  say  that  it  is  the  most 

Gray's  Anatomy  has  been  so  long  the  standard  of  I  complete  and  conveniently  arranged  text  book  of  its 
perfection  with  every  student  of  anatomy,  that  we  ■  kind,  is  to  repeat  what  each  generation  of  students 
need  do  no  more  than  call  attention  to  the  improve-  has  learned  as  a  tradition  r(  th"-  elders,  and  verified 
nient  in  the  present  edition. — Detroit  Review  of  Med.  by  personal  experience. — N.  Y.  Med.  Gazette,  Dec. 
and  Pharm.,  Aug.  1870.  1  17,  1870. 


^MITR  [HENRY H.),  M.D.,         and   JJORNER  (  WILLIAM  E.),  M.D., 

Prof  .of  Surgery  in  the  Univ.  of  Penna.,  *e.  Late  Prof .  of  Anatomy  in  the  Univ.  ofPenna.,ttc. 

AN    ANATOMICAL    ATLAS,  illustrative  of  the   Structure  of  the 

Human  Body.     In  one  volume,  large  imperial  octavo,  extra  cloth,  with  about  six  hundred 

and  fifty  beautiful  figures.     $4  50. 
The  plan  of  this  Atlas,  which  renders  it  so  pecn-  I  the  kind  that  has  yet  appeared  ;  and  we  must  add, 
liarly  convenient  for  the  student,  and  its  superb  ar-  |  the  very  beautiful  manner  in  which  it  is  "got  up," 
tistical  execution,  have  been  already  pointed  out.  We    is  so  creditable  to  the  country  as  to  be  flattering  to 
must  congratulate  the  student  upon  the  completion     our  national  pride.— .dwiericaij  JJfeciica/ ^owrnai. 
of  this  Atlas,  as  it  is  the  most  convenient  work  of  I 


gHARPEY  (  WILLIAM),  M.D.,      and       Q  UAIN  [JONES  Sf  RICHARD). 
HUMAN  ANATOMY.  Revised,  with  Notes  and  Additions,  by  Joseph 

Leidy,  M.D.,  Professor  of  Anatomy  in  the  University  of  Pennsylvania.     Complete  in  two 
large  octavo  volumes,  of  about  130U  pages,  with  511  illustrations;  extra  cloth,  $6  00. 
The  very  low  price  of  this  standard  work,  and  its  completeness  in  all  departments  of  the  subject, 
should  command  for  it  a  place  in  the  library  of  all  anatomical  students. 


H 


ODGES,  [RICHARD  M.),  M.D., 

Late  Demonstrator  of  Anatomy  in  the  Medical  Department  of  Harvard  University 

PRACTICAL  DISSECTIONS.     Second  Edition,  thoroughly  revised.     In 

one  neat  royal  12mo.  volume,  half-bound,  $2  00. 
The  object  of  this  work  is  to  present  to  the  anatomical  student  a  clear  and  concise  description 
of  that  which  he  is  expected  to  observe  in  an  ordinary  coutse  of  dissections.  The  author  has 
endeavored  to  omit  unnecessary  details,  and  to  present  the  subje  st  in  the  form  which  many  years' 
experience  has  shown  him  to  be  the  most  convenient  and  intelligible  to  the  student.  In  the 
revision  of  the  present  edition,  he  has  sedulously  labored  to  render  the  volume  more  worthy  of 
the  favor  with  which  it  has  heretofore  been  received. 


Henry  C.  Lea's  Publications — (Anatomy). 


rrriLsoN  (ebas31us),  f.e.s. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.    Edited 

by  W.H.  GoBRBCHT,  M.D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  Col- 
lege of  Ohio.     Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.     In 
one  large  and  handsome  octavo  volume,  of  over  60U  large  pages;  extra  cloth,  $4  00;  lea- 
ther, $0  00. 
The  publisher  trusts  that  the  well-earned  reputation  of  this  long-established  favorite  will  be 
more  than  maintained  by  the  present  edition.     Besides  a  very  thorough  revision  by  the  author    it 
has  been  most  carefully  examined  by  the  editor,  and  the  efforts  of  both  have  been  directed  to  in- 
troducing everything  which  increased  experience  in  its  use  has  suggested  as  desirable  to  render  it 
a  complete  text-book  for  those  seeking  to  obtain  or  to  renew  an  acquaintance  with  Human  Ana- 
tomy.    The  amount  of  additions  whiCh  it  has  thus  received  may  be  estimated  from  the  fact  that 
tht'  present  edition  contains  over  one-fourth  more  matter  than  the  last,  rendering  a  smaller  type 
and  an  enlarged  page  requisite  to  keep  the  volume  within  a  convenient  size.     The  author  has  not 
only  thus  added  largely  to  the  work,  but  he  has  also  made  alterations  throughout,  wherever  there 
appeared  the  opportunity  of  improving  the  arrangement  or  style,  so  as  to  present  every  fact  in  its 
most  appropriate  manner,  and  to  render  the  whole  as  clear  and  intelligible  as  possible.    The  editoi 
has  exercised  the  utmost  caution  to  obtain  entire  accuracy  in  the  text,  and  has  largely  increased 
the  number  of  illu^^trations,  of  which  there  are  about  one  hundred  and  filly  more  in  this  edition 
than  in  the  last,  thus  bringing  distinctly  before  the  eye  of  the  student  everything  of  interest  or 
importance. 

TIE  ATE  [CHRISTOPHER],  F.  R.  C.  S., 

•*■-»•  Teacher  of  Oijerative  Surgery  in  University  College,  London. 

PRACTICAL   ANATOMY:   A   Manual   of  Dissections.     From   the 

Second  revised  and  improved  London  edition.     Edited,  with  additions,  by  W.  \V.  Keen 

M.  D.,  Lecturer  on  Pathological  Anatomy  in  the  Jelferson  Medical  College,  Philadelphia. 

In  one  handsome  royal  12mo.  volume  of  578  pages,  with  247  illustrations.     Extra  cloth, 

$3  60 ;  leather,  $4  00.  {Lately  Ftcblished.) 
Dr.  Keen,  the  American  editor  of  this  work,  in  his 
preface,  says:  "In  presenting  this  American  edition 
of  'Heath's  Practical  Anatomy,'  I  feel  that  I  have 
been  instrumental  in  supplying  a  want  long  felt  for 
a  real  dissector's  manual,"  and  this  assertion  of  its 
editor  we  deem  is  fully  justified,  after  an  examina- 
tion of  its  contents,  for  it  is  really  an  excellent  work. 
Indeed,  we  do  not  hesitate  to  say,  the  best  of  its  class 
with  which  we  aro  acquainted  ;  resembling  "Wilson 
in  terse  and  clear  description,  excelling  most  of  the 
60-called  practical  anatomical  dissectors  in  the  scope 
of  the  subject  and  practical  selected  matter.  .  .  . 
In  reading  this  work,  one  is  forcibly  impressed  with 
the  great  pains  the  author  takes  to  impress  the  sub- 
ject upon  the  mind  of  the  student.  He  is  full  of  rare 
and  pleasing  little  devices  to  aid  memory  in  main- 
taining its  hold  upon  the  slippery  slopes  of  anatomy. 
— St.  Louis  Med.  and  Stirg.  Journal,  Mar.  10,  1871. 

It  appears  to  ns  certain  that,  as  a  guide  in  dissec- 
tion, and  as  a  work  containing  facts  ot  anatomy  in 
brief  and  easily  understood  lorm,  this  manual  is 
complete.  This  work  contains,  also,  very  perfect 
illustrations  of  parts  which  can  thus  be  more  easily 
understood  and  studied;  in  this  respect  it  compares 
favorably  with  works   of  much  greater  pretension. 


Such  manuals  of  anatomy  are  always  favorite  works 
with  medical  students.  We  would  earnestly  recom- 
mend this  one  to  their  atteution;  it  has  excellences 
which  make  it  valuable  as  a  guide  in  dissecting,  as 
well  as  in  studying  d.aa.iomy.— Buffalo  Medical  and 
Surgical  JuurnuL,  Jan.  1611. 

The  first  English  edition  was  issued  about  six  years 
ago,  and  was  favorably  received  not  only  on  account 
of  the  great  reputation  of  its  author,  but  also  from 
its  great  value  and  excellence  as  a  guide-book  to  the 
practical  anatomist.  The  Americau  edition  has  un- 
dergone some  alterations  and  additions  which  will 
no  doubt  enhance  its  value  materially.  The  conve- 
nience of  the  student  has  been  carefully  consulted  in 
the  arrangement  of  the  text,  and  the  directions  given 
for  the  prosecution  of  certain  dissections  will  be  duly 
appreciated. — Canada  Lancet,  Feb.  1S7I. 

This  is  an  excellent  Dissector's  Manual ;  one  which 
is  not  merely  a  descriptive  manual  of  anatomy,  but 
a  guide  to  the  student  at  the  dissecting  table,  enabling 
him,  though  a  beginner,  to  prosecute  his  work  intel- 
ligently, and  without  assistance.  The  American  edi- 
tor has  made  many  valuable  alterations  and  addi- 
tions to  the  original  work.— ^'W.  Journ.  ofOMetrica, 
Feb.  Ib7I. 


JUAGLISE  {JOSEPH). 

'^SURGICAL  ANATOMY.     By  Joseph  Maclise,  Surgeon.    In  one 

volume,  very  large  imperial  quarto;  with  68  large  and  splendid  plates,  drawn  in  the  best 
style  and  beautifully  colored,  containing  190  figures,  many  of  them  the  size  ot  lite;  logethei 
with  copious  explanatory  letter-press.      Strongly  and  handsomely  bound  in  extra  cloth 
Price  $14  00. 
As  no  complete  work  of  the  kind  has  heretofore  been  published  in  the  English  language,  the 
present  volume  will  supply  a  want  long  felt  in  this  country  of  an  accurate  and  comprehensive 
Atlas  of  Surgical  Anatomy,  to  which  the  student  and  practitioner  can  at  all  times  reter  to  ascer- 
tain the  exact  relative  positions  of  the  various  portions  of  the  human  frame  towards  each  other 
and  to  the  surface,  as  well  as  their  abnormal  deviations.     Notwithstanding  the  large  size,  beauty 
and  finish  of  the  very  numerous  illu.strations,  it  will  be  observed  that  the  price  is  so  low  as  to 
place  it  within  the  reach  of  all  members  of  the  profession. 

We  know  of  no  work  on  surgical  anatomy  which    refreshed   by  those   clear  and  distinct  disseciiono, 
.,  ,„  „i.i,  if       r „.,,..*  which  every  one  must  appreciate  who  has  a  particle 

of  enthusiasm.     The  English  medical  press  has  quite 


can  compete  with  it. — Lancet. 

The  work  of  Maclise  on  surgical  anatomy  is  of  the 
highest  value,  in  some  respects  it  Is  the  best  publi- 
cation of  its  kind  we  have  seen,  and  is  worthy  of  a 
place  in  the  libiary  of  any  medical  man,  while  the 
student  could  scarcely  make  a  better  investment  than 
this. — Tlie  Western  Journalof  Medicineand Surgery . 

No  such  lithographic  illustrations  of  surgical  re- 
gions have  hitherto,  we  think,  been  given.  While 
the  operator  is  shown  every  vessel  and  nerve  where 
an  operation  is  contemplated,  the  exact  anatomist  is 


exhausted  the  words  of  praise,  in  recommending  this 
admirable  treatise.  Those  who  have  any  curiosuy 
to  gratify,  in  reference  to  the  perfectibility  ot  the 
lithographic  art  in  delineating  the  complex  mechan- 
ism of  the  human  body,  are  invited  to  examine  our 
specimen  copy.  If  anything  will  induce  surgeons 
and  students  to  patronize  a  book  of  such  rare  value 
and  everyday  importance  to  them,  it  will  be  a  survey 
of  the  artistical  skill  exhibited  in  these  fac-eimiles  of 
nature. — Boston  Med.  and  Surg.  Journal. 


HOKNER'S  SPECIAL  ANATOMY  AND  HISTOLOGY. 
Eighth  edition,  extensively  revised  and  modified. 


In  2  vols.  8vo.,  of  over  1000  pages,  with  more  than 
300  wood-cuts  ;  extra  cloth,  ijiU  00. 


Henry  C.  Lea's  Publications — (Physiology). 


llfAE SHALL  {JOHN),  F.  R.  S., 

J.U.  Professor  of  Surgery  in  University  College,  London,  &e. 

OUTLINES  OF  PHYSIOLOGY,  HUMAN  AND  GOMPARATIYE. 

With  Additions  by  Francis  Gurnet  Smith,  M.  D.,  Professor  of  the  Institutes  of  Medi- 
cine in  the  University  of  Pennsylvania,  &c.  With  numerous  illustrations.  In  one  large 
and  handsome  octavo  volume,  of  1026  pages,  extra  cloth,  $6  60 ;  leather,  raised  bands, 
$7  60. 


In  fact,  in  every  respect,  Mr.  Marshall  has  present- 
ed us  with  a  most  complete,  reliable,  and  scieutiHc 
work,  and  we  feel  that  it  is  worthy  our  warmest 
commendation. — St.  Louis  Med.  Reporter,  Jan.  1869. 

This  is  an  elaborate  and  carefully  prepared  digest 
of  human  and  comparative  physiology,  designed  for 
the  use  of  general  readers,  but  more  especially  ser- 
viceable to  the  student  of  medicine.  Its  style  is  con- 
cise, clear,  and  scholarly;  its  order  perspicuous  and 
exact,  and  its  range  of  topics  extended.  The  author 
and  his  American  editor  have  been  careful  to  bring 
to  the  illustration  of  the  subject  the  important  disco- 
veries of  modern  science  in  the  various  cognate  de- 
partments of  investigation.  This  is  especially  visible 
in  the  variety  of  interesting  information  derived  from 
the  departments  of  chemistry  and  physics.  The  great 
amount  and  variety  of  matter  contained  in  the  work 
Is  strikingly  illustrated  by  turning  over  the  copious 
index,  covering  twenty-four  closely  printed  pages  in 
double  columns. — Sillimun's  Journal,  .Tan.  1S69. 

We  doubt  if  there  is  in  the  English  language  any 
compend  of  phy.siolugy  more  useful  to  the  student 
than  this  work. — St.  Louis  Med.  and  Surg.  Journal, 
Jan.  1869. 

It  quite  fulfils,  in  our  opinion,  the  author's  design 
of  making  it  truly  edttcrtiionoZ  in  its  character — which 
is,  perhaps,  the  highest  commendation  that  can  be 
asked. — Am.  Journ.  Med.  Sciences,  Jan.  1869. 

We  may  now  congratulate  him  on  having  com- 
pleted the  latest  as  well  as  the  best  summary  of  mod- 


ern physiological  science,  both  human  and  compara- 
tive, with  which  we  are  acquainted.  To  speak  of 
this  work  in  the  terms  ordinarily  used  on  such  occa- 
sions would  not  be  agreeable  to  ourselves,  and  would 
fail  to  do  justice  to  its  author.  To  write  such  a  book 
requires  a  varied  and  wide  range  of  knowledge,  con- 
siderable power  of  analysis,  correct  judgment,  skill 
in  arrangement,  and  conscientious  spirit.  It  must 
have  entailed  great  labor,  but  now  that  the  task  has 
been  fulfilled,  the  b'jok  will  prove  not  onlyiuvaluable 
to  the  student  of  medicine  and  surgery,  but  service- 
able to  all  candidates  in  natural  science  examinations, 
to  teachers  in  schools,  and  to  the  lover  of  nature  gene- 
rally. In  conclusion,  we  can  only  express  the  con- 
riction  that  the  merits  of  the  work  will  command  for 
it  that  success  which  the  ability  and  vast  labor  dis- 
played in  its  production  so  well  deserve. — London 
Lancet,  Feb.  22,  1S6S. 

If  the  possession  of  knowledge,  and  peculiar  apti- 
tude and  skill  in  expounding  it,  qualify  a  man  to 
write  an  educational  work,  Mr.  Marshall's  treatise 
might  be  reviewed  favorably  without  even  opening 
the  covers.  Thereare  lew,  if  any,  moreacconiplished 
anatomists  and  physiologists  than  the  distinguished 
professor  of  surgery  at  University  College  ;  and  he 
has  long  enjoyed  the  highest  reputation  as  a  teacher 
of  physiology,  possessing  remarkable  powers  of  clear 
exposition  and  graphic  illustiation.  We  have  rarely 
the  pleasure  of  being  able  to  recommend  a  text-book 
so  unreservedly  as  this. — British  Med.  Journal,  Jan. 
2.5,  18tJ8. 


pARPENTER  {WILLIAM  B.),  M.D.,  F.R.S., 

^  Examiner  in  Physiology  and  Oomparative  Anatomy  in  the  University  of  London. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief  appli- 

cations  to  Psychology,  Pathology,  Therapeutics,  Hygiene  and  Forensic  Medicine.  A  new 
American  from  the  last  and  revised  London  edition.  AVith  nearly  three  hundred  illustrations. 
Edited,  with  additions,  by  Francis  Gurney  Smith,  M.  D.,  Professor  of  the  Institutes  of 
Medicine  in  the  University  of  Pennsylvania,  Ac.  In  one  very  large  and  beautiful  octavo 
volume,  of  about  900  large  pages,  handsomely  printed;  extra  cloth,  $6  60;  leather,  raised 
bands,  $6  60. 

We  doubt  not  it  Is  destined  to  retain  a  strong  hold 
on  public  favor,  and  remain  the  favorite  text-book  in 
our  colleges. — Virginia  Medical  Journal. 


With  Dr.  Smith,  we  confidently  believe  "that  the 
present  will  more  than  sustain  the  enviable  reputa- 
tion already  attained  by  former  editions,  of  being 
one  of  the  fullest  and  most  complete  treatises  on  the 
subject  in  the  English  language."  We  know  of  none 
from  the  pages  of  which  a  satisfactory  knowledge  of 
the  physiology  of  the  human  organism  can  be  as  well 
obtained,  none  better  adapted  for  the  use  of  such  as 
take  up  the  study  of  physiology  in  its  reference  to 
the  instit-ates  and  practice  of  medicine. — Am..  Jour. 
Med.  Sciences. 


The  above  is  the  title  of  what  is  emphatically  tht 
great  work  on  physiology ;  and  we  are  conscious  that 
it  would  be  a  useless  effort  to  attempt  to  add  any- 
thing to  the  reputation  of  this  invaluable  work,  and 
can  only  say  to  all  with  whom  our  opinion  has  any 
induence,  that  it  is  our  autlwrUy. — Atlanta  Med. 
■Journal. 


or  THE  SAME  AUTHOR. 

PRINCIPLES  OF  COMPARATIYE  PHYSIOLOGY.    New  Ameri- 

can,  from  the  Fourth  and  Revised  London  Edition.     In  one  large  and  handsome  octavo 
volume,  with  over  three  hundred  beautiful  illustrations      Pp.762.    Extra  cloth,  $5  00. 
As  a  complete  and  condensed  treatise  on  its  extended  and  important  subject,  this  work  becomes 

a  neces.sity  to  students  of  natural  science,  while  the  very  low  price  at  which  it  ig  offered  places  it 

within  the  reach  of  all. 


JT'IRKES  {WILLIAM  SENHOUSE),  21. D. 

A  MANUAL  OF  PHYSIOLOGY.     A  new  American  from  the  third 

and  improved  London  edition.     With  two  hundred  illustrations.     In  one  large  and  hand- 
some royal  12mo.  volume.     Pp.  686.     Extra  cloth,  $2  26  ;  leather,  $2  75. 
It  is  at  once  convenient  in  size,  comprehensive  In  |  lent  guide  in  the  study  of  physiology  in  its  most  ad- 


design,  and  concise  in  statement,  and  altogether  well 
adapted  for  the  purpose  designed. — St.  Louis  Med. 
and  Surg.  Journal. 

The  physiological  reader  will  Hud  It  ft  most  axcel- 


vanced  and  perfect  form.  The  author  has  shown 
himself  capable  of  giving  details  sufficiently  ample 
in  a  condensed  and  concentrated  shape,  on  a  science 
in  which  it  is  necessary  at  once  to  be  correct  and  not 
lengthened. — Edinburgh  Med.  and  Surg.  Journal. 


Henry  C.  Lea's  Publications — (Physiology). 


J}ALTON  {J.  C),  M.D., 

■»-'  Professor  of  PhysUilogy  in  the  Oollege  of  Physicians  and  Surgeons,  New  York,  &c. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.    Designed  for  the  use 

of  students  and  Practitioners  of  Medicine.  Fifth  edition,  revised,  with  nearly  three  hun^ 
dred  illustrations  on  wood.  In  one  very  beautiful  octavo  volume,  of  over  700  pages,  extia 
cloth,  $5  25;  leather,  $6  25.     (Jjist  Issued.) 

Preface  to  the  Fifth  Edition. 
In  preparing  the  present  edition  of  this  work,  the  general  plan  and  arrangement  of  the  previous 
editions  have  been  retained,  so  far  as  they  have  been  found  useful  and  adapted  to  the  purposes  uf 
a  test-book  for  students  of  medicine.  The  incessant  advance  of  all  the  natural  and  physical 
sciences,  never  more  active  than  within  the  last  five  years,  has  furnished  many  valuable  aids  to 
the  special  investigations  of  the  physiologist;  and  the  progress  of  physiological  research,  during 
the  same  period,  has  required  a  careful  revision  of  the  entire  work,  and  the  modification  or  re- 
arrangement of  many  of  its  parts.  At  this  day,  nothing  is  regarded  as  of  any  value  in  natural 
science  which  is  not  based  upon  direct  and  intelligible  observation  or  experiment;  and,  accord- 
ingly, the  discussion  of  doubtful  or  theoretical  questions  has  been  avoided,  as  a  general  rule,  in 
the  present  volume,  while  new  facts,  from  whatever  source,  if  fully  established,  hiive  been  added 
and  incorporated  with  the  results  of  previous  investigation.  A  number  of  new  illustrations  have 
been  introduced,  and  a  few  of  the  older  ones,  which  seemed  to  be  no  longer  useful,  have  been 
omitted.  In  all  the  changes  and  additions  thus  made,  it  has  been  the  aim  of  the  writer  to  make  the 
book,  in  its  present  form,  a  faithful  exponent  of  the  actual  conditions  of  physiological  science. 
New  Tore,  October,  1871. 
In  this,  the  standard  text-book  on  Physiology,  all  that  is  needed  to  maintain  the  favor  with  which 
it  is  regarded  by  the  profession,  is  the  author's  assurance  that  it  has  been  thoroughly  revised  and 
brought  up  to  a  level  with  the  advanced  science  of  the  day.  To  accomplish  this  has  required 
some  enlargement  of  the  work,  but  no  advance  has  been  made  in  the  price. 


The  fifth  edition  of  this  truly  valuable  work  on 
Human  Physiology  comes  to  us  with  many  valuable 
improveraeuts  and  additions.  As  a  text-book  of 
physiology  the  work  of  Prof.  Dalton  has  long  been 
well  known  as  one  of  the  best  which  could  be  placed 
in  the  hands  of  student  or  practitioner.  Prof.  Dalton 
has,  in  the  several  editions  of  his  work  heretofore 
published,  labored  to  keep  step  with  the  advancement 
iu  science,  and  the  last  edition  shows  by  its  improve- 
ments on  former  ones  that  he  is  determined  to  main- 
tain the  high  standard  of  his  work.  We  predict  for 
the  present  edition  increased  favor,  though  this  work 
has  long  been  the  favorite  standard. — Buffalo  Med. 
and  Surg.  Journal,  April,  1872. 

An  extended  notice  of  a  work  so  generally  and  fa- 
vorably known  as  this  is  unnecessary.  It  is  justly 
regarded  as  one  of  the  most  valuable  text-books  on 
the  subject  in  the  English  language. — St.  Louit  Med. 
Archives,  May,  1872. 

We  know  no  treatise  in  physiology  so  clear,  com- 
plete, well  assimilated,  and  perfectly  digested,  as 
Dalton's.  He  never  writes  cloudily  or  dubiously,  or 
in  mere  quotation.  He  assimilates  all  his  material, 
and  from  it  constructs  a  homogeneous  transparent 
argument,  which  is  always  honest  and  well  informed, 
and  hides  neither  truth,  ignorance,  nor  doubt,  so  far 
as  either  belongs  to  the  subject  in  hand. — Bj-it.  Med. 
loitrnal,  March  23,  1872. 


Dr.  Dalton's  treatise  is  well  known,  and  by  many 
highly  esteemed  iu  this  country.  It  is,  indeed,  a  good 
elementary  treatise  on  the  subject  it  professes  to 
teach,  and  may  safely  be  put  into  the  hands  of  Eng- 
lish students.  It  has  one  great  merit — it  is  clear,  and, 
on  the  whole,  admirably  illustrated.  The  part  we 
have  always  esteemed  most  highly  is  that  relating 
to  Embryology.  The  diagrams  given  of  the  various 
stages  of  development  give  a  clearer  view  of  the  sub- 
ject than  do  those  in  general  use  iu  this  country ;  and 
the  text  may  be  said  to  be,  upon  the  whole,  equally 
clear. — London  Med.  Times  and  Gazette,  March  23, 
1872. 

Dalton's  Physiology  is  already,  and  deservedly, 
the  favorite  text-book  of  the  majority  of  American 
medical  students.  Treating  a  most  iutere.sting  de- 
partment of  science  in  his  own  peculiarly  lively  and 
fascinating  style,  Dr.  Dalton  carries  his  reader  along 
without  effort,  and  at  the  same  time  impresses  upon 
his  mind  the  truths  taught  much  more  successfully 
than  if  they  were  buried  beneath  a  multitude  of 
words. — Kansas  City  Med.  Journal,  April,  1872. 

Professor  Dalton  is  regarded  j  ustly  as  the  authority 
in  this  country  on  physiological  subjects,  and  the 
fifth  edition  of  his  valuable  work  fully  j  nstifies  the 
exalted  opinion  the  medical  world  has  of  his  labors. 
This  last  edition  is  gri'atly  enlarged  —Virginia  Clin- 
ical Record,  April,  1872. 


fiUNGLISON  [ROBLEY),  M.D., 

■^-^  Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

HUMAN  PHYSIOLOGY.     Eighth  edition.     Thoroughly  revised  and 

extensively  modified  and  enlarged,  with  five  hundred  and  thirty-two  illu.strations.      In  two 
large  and  handsomely  printed  octavo  volumes  of  about  1500  pages,  extra  cloth.     $7  00. 


T  EHMANN  [C.  G.). 

PHYSIOLOGICAL  CHEMISTRY.  TransLated  from  the  second  edi- 
tion by  George  E.  Day,  M.  D.,  F.  R.  S.,  Ac,  edited  by  R.  E.  Rogers,  M.  D.,  Profe.ssor  of 
Chemistry  in  the  Medical  Department  of  the  University  of  Penn.sylv.ania,  with  illustration>? 
selected  from  Funke's  Atlas  of  Physikilogical  Chemistry,  and  an  Appendix  of  plates.  Com- 
plete in  two  large  and  handsome  octavo  volumes,  containing  1200  pages,  with  nearly  two 
hundred  illustrations,  extra  cloth.     $6  00. 


T>r  THB  SAME  AUTHOR. 

MANUAL  OF  CHEMICAL  PHYSIOLOGY.    Translated  from  the 

German,  with  Notes  and  Additions,  by  J.  Cheston  Morris,  M.  D.,  with  an  Introductory 
Essay  on  Vital  Force,  by  Professor  Samuel  Jackson,  M.  D.,  of  the  University  of  Pennsyl- 
vania. With  illustrations  on  wood.  In  one  very  h.andsome  octavo  volume  of  336  page?, 
extra  cloth.     $2  25. 


10 


Henry  C.  Lea's  Publications — (Chemistry). 


ATTFIELD  {JOHN),  Ph.D., 

Professor  of  Practical  Chemistry  to  the  Phnrmnccuticnl  Society  of  Great  Britain,  A-c. 

CHEMISTRr,   GENERAL,  MEDICAL,  AND  PHARMACEUTICAL; 

irichuling  the  Chemistry  of  the  U.  S.  Pharmnoopoeia.     A  Manunl  of  the  Genernl  Principlea 
of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.     Fifih  Edition,  revised 
by  the  author.     In  one  handsome  royal  12mo.  volume.     {Nearly  Ready.) 
We  commend  the  work  heartily  a?  one  of  the  best  I  rican   work— we  allude   to  the  infrodnction   of  the 


text-books  extant  for  the  medical  student. — Detroit 
Rev.  of  Med.  and  Pharm.,  Feb.  1872. 

The  best  work  of  the  kind  in  the  English  language. 
.—N.  T.  Psychological  Journal,  .Tan.  1872. 

The  work  is  constructed  with  direct  reference  to 
the  wants  of  medical  and  pharmaceutical  students; 
and,  although  an  English  work,  the  points  of  differ- 
ence between  the  British  and  United  States  Pharma- 
copoeias are  indicated,  making  it  as  useful  here  as  in 
England.  Altogether,  the  book  is  one  we  can  heart- 
ily recommend  to  practitioners  as  well  as  students. 
—N.  Y.  Med.  Journal,  Dec.  1S71. 

It  differs  from  other  text-books  in  the  following 
particulars  :  iirst,  in  the  exclusion  of  matter  relating 
to  compounds  which,  at  present,  are  only  of  interest 
to  the  scientific  chpmi.«t ;  secondly,  in  containinc  the 
chemistry  of  every  substance  recognized  officially  or 
in  general,  as  a  remedial  agent.  It  will  be  found  a 
most  valuable  book  for  pupils,  assistants,  and  others 
engaged  in  medicine  and  pharmacy,  and  we  henrtily 
commend  it  to  our  readers. — Canada  Lancet,  Oct. ■ 
1871. 

When  the  original  English  edition  of  thi.owork  was 
published,  we  had  occasion  to  express  our  high  ap- 
preciation of  its  worth,  and  also  to  review,  in  con- 
siderable detail,  the  main  features  of  the  book.  As 
the  arrangement  of  subjects,  and  the  main  part  of 
the  text  of  the  present  edition  are  similar  to  the  for- 
mer publication,  it  will  be  needless  for  us  to  go  over 
the  ground  a  second  time  ;  we  may,  however,  call  at- 
tention to  a  marked  advantage  possessed  by  the  Arne- 


cheraistry  of  the  preparations  of  the  United  States 
Pharmacopoeia  as  well  as  that  relating  to  the  Briti.sh 
authority.  —  Canadian  Pharmaceutical  Journal, 
Nov.  1S71. 

Chemistry  has  borne  the  name  of  being  a  hard  sub- 
ject to  master  by  the  student  of  medicine,  and 
chiefly  because  so  much  of  it  consists  of  compounds 
only  of  interest  to  the  scientific  chemist ;  in  this  work 
sucii  portions  are  modified  or  altogether  left  out,  and 
in  the  arrangement  of  the  subject  matter  of  the  work, 
practical  utility  is  soueht  after,  and  we  think  fully 
attHined.  We  commend  it  for  its  clearness  and  order 
to  both  teacher  and  pupil. — Oregon  Med.  and  Surg. 
Reporter,  Oct.  1871. 

It  contains  a  most  admirable  digest  of  what  is  spe- 
cially needed  by  the  medical  student  in  all  that  re- 
lates to  practical  chemistry,  and  consitutes  for  him 

a  sound  and  useful  text-book  on  the  subject 

We  commend  it  to  the  noticeof  every  medical,  as  well 
as  pharmaceutical,  student.  We  only  regret  that  we 
had  not  the  book  to  depend  upon  in  working  up  the 
su1>ject  of  practical  and  pharmaceutical  chemistry  for 
the  University  of  London,  for  which  it  seems  to  us 
that  it  is  exactly  adapted.  This  is  paying  the  book  a 
high  compliment. — Tlte  Lancet. 

Dr.  Attfield'.s  book  is  written  in  a  clear  and  able 
manner;  it  is  a  work  sui  generis  Andi  without  a  rival ; 
it  will  be  welcomed,  we  think,  by  every  reader  of  the 
'Pharmacopoeia,'  and  is  quite  as  well  suited  for  the 
medical  student  as  for  the  pharmacist. — The  Chemi- 
cal News. 


TU'OITLER  AND  FTTTIG. 

'^    OUTLINES  OF  ORGANIC  CHEMISTRY.     Translated  with  Ad- 
ditions from  the  Eifchth  German  Edition.     By  Ira  Remsen,  M.D.,  Ph.D.,  Profe.sssor  of 
Chemistry  and  Physics  in  Williams  College,  Mass.     In  one  handsome  volume,  royiil  12mo. 
of  550  pp.  extra  cloth,  %^.     {Just  Ready.) 
As  the  numerous  editions  of  the  original  .nttest,  this  work  is  the  leading  text-hook  and  standard 
authority  throughout  Germany  on  its  importtint  and  intricate  subject — a  position  won  for  it  by 
the  clearness  and  conciseness  which  are  its  distinguishing  ch.Traeteristics.     The  translation  has 
.been  executed  with  the  approbation  of  Profs.  AVbhler  and  Fittig,  and  numerous  adiiitions  and 
alterations  have  been  introduced,  so  as  to  render  it  in  every  respect  on  a  level  with  the  most 
advanced  condition  of  the  science. 

QDLING  ( WILLIAM), 

^-^  Lecturer  on  Chemistry  at  St.  Bartholomew's  HospUxl,  <te. 

A  COURSE  OF  PRACTICAL  CHEMISTRY,  arranged  for  the  Use 

of  Medical  Students.  With  Illustrations.  From  the  Fourth  and  Revised  London  Edition. 
In  one  neat  royal  12mo.  volume,  extra  cloth.  $2.  {Lately  Issued.) 
As  a  work  for  the  practitioner  it  cannot  be  excelled.  I  ganic  chemistry,  etc.  The  portions  devoted  to  a  dis- 
It  is  written  plainly  and  concisely,  and  gives  in  a  very  cussion  of  these  subjects  are  very  excellent.  In  no 
small  compass  the  information  required  by  the  busy  I  work  can  the  physician  find  more  that  is  valuable 
practitioner.  It  is  essentially  a  work  for  the  physi-  I  and  reliable  in  regard  to  urine,  bile,  milk,  bone,  uri- 
cian,and  no  one  who  purchases  it  will  ever  regret  the  j  nary  calculi,  tissue  composition,  etc.  The  work  is 
outlay.  In  addition  to  all  that  is  usually  given  in  1  small,  reasonable  in  price,  and  well  published.— 
connection  with  inorganic  chemistry,  there  are  most  Richmond  and  Louisville  Med.  Journal,  Dec.  1869. 
valuable  contributions  to  toxicology,  animal  and  or- 1 


riALLOWAY  {ROBERT),  F.C.S., 

^-^  Prof  of  Applied  Chemistry  in  the  Royal  College  of  Science  for  Ireland,  &c. 

A  MANUAL  OF  QUALITATIVE  ANALYSIS.     From  tlie  Fifth  Lon- 

d(»  Edition.    In  one  neat  royal  12mo.  volume,  with  illustrations;  extra  cloth,  $2  50.     {J?(st 

Issued.) 
The  success  which  has  carried  this  work  through  repeated  editions  in  England,  and  its  adoption 
as  a  text-book  in  several  of  the  leading  institutions  in  this  country,  show  that  the  author  has  suc- 
ceeded in  the  endeavor  to  produce  a  sound  practical  manual  and  book  of  reference  for  the  che- 
mical student. 


Prof.  Galloway's  books  are  deservedly  in  high 
esteem,  and  this  .^mericau  reprint  of  the  fifth  edition 
(1869)  of  his  manual  of  Qualitative  Analy.^is,  will  be 
acceptable  to  many  American  students  to  whom  the 
English  editiiin  is  not  accessible. — Am.  Jour,  of  Sci- 
ence and  Arts,  Sept.  1872. 


We  regard  this  volume  as  a  valuable  addition  to 
the  chemical  text-books,  and  as  particularly  calcu- 
lated to  instruct  the  student  in  analytical  researches 
of  the  inorganic  compounds,  the  important  vegetable 
acids,  and  of  compounds  and  various  tecrelions  and 
excretions  of  animal  origin. — Am,.  Journ.  of  Pharm., 
Sept.  1872. 


Henry  C.  Lea's  Publications — {Chemistry^  Pharmacy, &c.).       11 


flHANDLER  [CHARLES  F.).      and     flHANDLER  [WILLIAM  H.), 

\y  Prof,  of  Ckemintryinthe  N.  r.  Coll.  of  \^  Pmf  nf  Qhe.mistry  in,  the  Lehigh 

Pharmacy.  University. 

THE    AMERICAN    CHEMIST:    A  Monthly  Journal  of  Theoretical, 

Analyticnl,  and  Technical  Chemistry.  Each  number  averaging  forty  large  double  col- 
uiuned  pages  of  reading  matter.    Price  $5  per  annum  in  advance.    Single  number?,  60  cts. 

D;^  Specimen  numbers  to  parties  proposing  to  subscribe  will  be  sent  to  any  address  on  receipt 
of  25  cents. 

*^*  Subscriptions  can  begin  with  any  number. 

The  rapid  growth  of  the  Science  of  Chemistry  and  its  infinite  applications  to  other  sciences 
and  art?  render  a  journal  specially  devoted  to  the  subject  a  necessity  to  those  whose  pursuits 
require  familiarity  with  the  details  of  the  science.  It  has  been  the  aim  of  the  conductors  of  "  The 
American  Chemist"  to  supply  this  want  in  its  broadest  sense,  and  the  reputation  which  the 
periodical  has  alreaily  attained  is  a  sufficient  evidence  of  the  zeal  and  ability  with  which  they 
have  discharged  their  task. 

Assisted  by  an  able  body  of  collaborators,  their  aim  is  to  present,  within  a  moderate  compass, 
an  abstract  of  the  progress  of  the  science  in  all  its  departments,  scientifio  and  technical.  Import- 
ant original  communications  and  selected  papers  are  given  in  full,  and  the  standing  of  the  "  Chem- 
ist" is  such  as  to  secure  the  contributions  of  leading  men  in  all  portions  of  the  country.  Besides 
this,  over  one  hundred  journals  and  transactions  of  learned  societies  in  America,  Great  Britain, 
France,  Belgium,  Italy,  Russia,  and  Germany  are  carefully  scrutinized,  and  whatever  they  offer 
of  interest  is  condensed  and  presented  to  the  reader.  In  this  work,  which  forms  a  special  feature 
of  the  "Chemist,"  the  editors  have  the  assistance  of  M.  Alsberg,  Ph.D.,  Prof.  G.  F.  Barker,  T. 
M.  Blossom,  E.M.,  H.  C.  Bolton,  Ph.D.,  Prof.  T.  Egleston,  E.M  ,  H.  Endemann,  Ph.D.,  Prof.  C. 
A.  Goessraann,  Ph.D.,S.  A.  Goldschmidt,  A.M.,  E.M.,  E.  J.  Hailock.  Prof.  C.  A.  Joy,  Ph.D., 
J.  P.  Kimball,  Ph.D.,  0.  G.  Mason,  H.  Newton,  E.M.,  Prof.  Frederick  Prime,  Jr.,  Prof.  Paul 
Schweitzer,  Ph.D.,  Waldron  Shapleigh,  Romyn  Hitchcock,  and  Elwyn  Waller,  E.M.  From  the 
thoroughness  and  completeness  with  which  this  department  is  conducted,  it  is  believed  that  no 
periodical  in  either  hemisphere  more  faithfully  reflects  the  progress  of  the  science,  or  presents  a 
larger  or  more  carefully  garnered  store  of  information  to  its  readers. 


F' 


OWNES  [GEORGE),  Ph.D. 
A  MANUAL  OF  ELEMENTARY  CHEMISTRY;   Theoretical  and 

Practical.  With  one  hundred  and  ninety-seven  illustrations.  A  new  American,  from  the 
tenth  and  revised  London  edition.  Edited  by  Robert  Bridges,  M.  D.  In  one  large 
royal  12mo.  volume,  of  about  850  pp.,  extra  cloth,  $2  75  ;  leather,  $3  25.    {Lately  Issued.) 


This  work  is  so  well  known  that  it  seems  almost 
gnperfluous  for  us  to  speak  about  it.  It  has  been  a 
favorite  text-book  with  medical  students  for  years, 
and  its  popularity  has  in  no  respect  diminished. 
Whenever  we  have  been  consulted  by  medical  stu- 
dents, as  has  frequently  occurred,  what  treatise  on 
chemistry  they  should  procure,  we  have  always  re- 
commended Fownea',  for  we  regarded  it  as  the  best. 
There  is  no  work  that  combines  so  many  excellen- 
ces. It  is  of  convenient  size,  not  prolix,  of  plain 
perspicuous  diction,  contains  all  the  most  recent 
discoveries,  and  is  of  moderate  price. — Cincinnati 
Med.  Repertory,  Aug.  1S69. 

Large  additions  have  been  made,  especially  in  the 
department  of  organic  chemistry,  and  we  know  of  no 
other  work  that  has  greater  claims  on  the  physician, 
pharmaceutist,  or  student,  than  this.  We  cheerfully 
recommend  It  as  the  best  text-book  on  elementary 
chemistry,  and  bespeak  for  it  the  careful  attention 
of  students  of  pharmacy. — Chicago  Pharmacist,  Aug. 
1869. 

The  American  reprint  of  the  tenth  revised  and  cor- 
rected English  edition  is  now  issued,  and  represents 
the  present  condilion  of  the  science.  No  comments 
are  necessary  to  insure  it  a  favorable  reception  at 
the  hands  of  practitioneis  and  students.  —  Boston 
Med.  and  Surg.  Journal,  Aug.  12,  1S69. 

Here  is  a  new  edition  which  has  been  long  watched 
for  by  eager  teachers  of  chemistry.     In  its  new  garb, 


and  under  the  editorship  of  Mr.  Watts,  it  has  resumed 
its  old  place  as  the  most  successful  of  text-books. — 
Indian  Medical  Gazette,  Jan.  1,  1869. 

It  will  continue,  as  heretofore,  to  hold  the  first  rank 
is  a  text-book  for  students  of  medicine. — Chicago 
Med.  Examiner,  Aug.  18(59. 

This  work,  long  the  recognized  Manual  of  Chemistry, 
appears  as  a  tenth  edition,  under  the  able  editorship 
if  Bence  Jones  and  Henry  Watts.  The  chapter  on 
the  General  Principles  of  Chemical  Philosophy,  and 
the  greater  part  of  the  organic  chemistry,  have  been 
jewritten,  and  the  whole  work  revised  in  accordance 
with  the  recent  advances  in  chemical  knowledge.  It 
remains  the  standard  text-book  of  chemistry. — Dub- 
lin Quarterly  Journal,  Feb.  1869. 

There  is  probably  not  a  student  of  chemistry  in  this 
country  to  whom  the  admirable  manual  of  the  late 
Professor  Fownes  is  unknown.  It  has  achieved  a 
success  which  we  believe  is  entirely  without  a  paral- 
lel among  scientific  text-books  in  our  language.  This 
success  has  arisen  from  the  fact  that  there  is  no  En- 
glish work  on  chemistry  which  combines  so  many 
excellences.  Of  convenient  size,  of  attractive  form, 
clear  and  concise  in  diction,  well  illustrated,  and  of 
moderate  price,  it  would  seem  that  every  reviuisite 
for  a  student's  hand-bonk  has  been  attained.  —  The 
Chemical  News,  Feb.  1869. 


^0  WMAN  [JOHN  E.) ,  M.  D. 

PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.    Edited 

by  C.  L.   Bloxam,   Professor  of  Practical  Chemistry  in  King's  College,  London.       Fifth 
American,  from  the  fourth  and  revised  English  Edition.     In  one  neat  volume,  royal  12mo., 
pp.  351,  with  numerous  illustrations,  extra  cloth.     $2  25. 
_gr  THE  SAME  AUTHOR.  

INTRODUCTION   TO   PRACTICAL  CHEMISTRY,  INCLUDING 

ANALYSIS.     Fifth  American,  from  the  fifth  and  revised  London  edition.     With  numer- 
ous illustrations.     In  one  neat  vol.,  royal  12mo.,  extra  cloth.     $2  25. 


KNAPP'S  TECHNOLOGY  ;  or  Chemistry  Applied  to 
the  Arts,  and  to  Manufactures.  With  American 
additions,  by  Prof.  Walter  R.  Johkbon.    In  two 


very  handsome  octavo  volumes,  with  600   Tocd 
engravings,  extra  cloth,  $6  00. 


12       Henry  C.  Lea's  Publications — (Mat.  3Ied.  and  Therapeutics). 


pARRlSH  {ED  WARD), 

•^  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy. 

A  TREATISE  ON  PHARMACY.     Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  Formulae  and 
Prescriptions.  Third  Edition,  greatly  improved.  In  one  handsome  octavo  volume,  of  850 
pages,  with  several  hundred  illustrations,  extra  cloth.     $5  00;  leather,  $6  00. 

The  immense  amount  of  practical  information  condensed  in  this  volume  may  be  estimated  from 
the  fact  that  the  Index  contains  about  4700  items.  Under  the  head  of  Acids  there  are  312  refer- 
ences; under  Emplastrum,  36;  Extracts,  159;  Lozenges,  25;  Mixtures,  65;  Pills,  56;  Syrups, 
131;  Tinctures,  138;  Unguentum,  57,  <&o. 

We  have  examined  this  large  volume  with  a  good 
deal  of  care,  and  find  that  the  author  has  completely 
exhausted  the  subject  upon  which  he  treats  ;  a  more 
complete  work,  we  think,  it  would  be  impossible  to 
find.  To  the  student  of  pharmacy  the  work  is  indis- 
pensable ;  indeed,  so  far  as  we  know,  it  is  the  only  one 
of  its  kind  in  existence,  and  even  to  the  physician  or 
medical  student  who  can  spare  five  dollars  to  pur- 
chase it,  we  feel  sure  the  practical  information  he 
will  obtain  will  more  than  compensate  him  for  the 
outlay. — Canada  Med.  Journal,  Nov.  186-1. 

The  medical  student  and  the  practising  physician 
will  find  the  volume  of  inestimable  worth  for  study 
and  reference. — iS'a?i  Francisco  Mtd.  Press,  July, 
1864. 

When  we  say  that  this  book  is  in  some  respects 
the  best  which  has  been  published  on  the  subject  in 
the  English  language  for  a  great  many  years,  we  do 


not  wish  it  to  be  understood  as  very  extravagant 
praise.  In  truth,  it  is  not  so  much  the  best  as  the 
only  book. — The  London  Chemical  News. 

An  attempt  to  furnish  anything  like  an  analysis  oJ 
Parrish's  very  valuable  and  elaborate  Treatise  on 
Practical  Pharmacy  would  require  more  space  than 
we  have  at  our  disposal.  This,  however,  is  not  so 
much  a  matter  of  regret,  inasmuch  as  it  would  be 
difficult  to  think  of  any  point,  however  minute  and 
Apparently  trivial,  connected  with  the  manipulation 
if  pharmaceutic  substances  or  appliances  which  hag 
not  been  clearly  and  carefully  discussed  in  this  vol- 
ume. Want  of  space  prevents  our  enlarging  further 
on  this  valuable  work,  and  we  must  conclude  by  a 
simple  expression  of  our  hearty  appreciation  of  itf 
merits. — Duhliii  Qiuirterly  Jour,  of  Medical  Science, 
August,  lSt)4. 


^TILLE  {ALFRED),  M.D., 

A3  Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History 
Fourth  edition,  revised  and  enlarged.    In  two  large  and  handsome  octavo  volumes.     {Pre- 

paring.) 


Dr.  Stille's  splendid  work  on  therapeutics  and  ma- 
teria medica. — London  Med.  Times,  April  8,  186.5. 

Dr.  Still6  stands  to-day  one  of  the  best  and  most 
honored  representatives  at  home  and  abroad,  of  Ame- 
rican medicine;  and  these  volumes,  a  library  in  them- 
selves, a  treasure-house  for  every  studious  physician, 
assure  his  fame  even  had  he  done  nothing  more. — The 
Western  Journal  of  Medicine,  Dec.  1868. 

We  regard  this  work  as  the  best  one  on  Materia 
Medica  in  the  English  language,  and  as  such  it  de- 
serves the  favor  it  has  received. — Am.  Joum.  Medi- 
cal Sciences,  July  1868. 

We  need  not  dwell  on  the  merits  of  the  third  edition 
of  this  magnificently  conceived  work.  It  is  the  work 
on  Materia  Medica,  in  which  Therapentics  are  prima- 
rily considered — the  mere  natural  history  of  drugs 
being  briefly  disposed  of.  To  medical  practitioners 
this  is  a  very  valuable  conception.  It  is  wonderful 
how  much  of  the  riches  of  the  literature  of  Materia 
Medica  has  been  condensed  into  this  book.  The  refer- 
ences alone  would  make  it  worth  possessing.  But  it 
is  not  a  mere  compilation.  The  writer  exercises  a 
good  judgment  of  his  own  on  the  great  doctrines  and 
points  of  Therapeutics.  For  purposes  of  practice, 
Stmt's  book  is  almost  unique  as  a  repertory  of  in- 
formation, empirical  and  scientific,  on  the  actions  and 
uses  of  medicines. — London  Lancet,  Oct.  31,  1868. 

Through  the  former  editions,  the  professional  world 
Is  well  acquainted  with  this  work.     At  home  and 


abroad  its  reputation  as  a  standard  treatise  on  Materia 
Medica  is  securely  established  It  is  second  to  no 
work  on  the  subject  in  the  English  tongue,  and,  in- 
deed, is  decidedly  superior,  in  some  x'espects,  to  any 
other. — Pacific  Med.  and  Surg  Journal,  July,  1868. 

Still6'»  Therapeutics  is  incomparably  the  best  work 
on  the  subject.— A^.  X.  Med.  Gazette,  Sept.  26,  1868. 

Dr  Still6's  work  is  becoming  the  best  known  of  any 
of  our  treatises  on  Materia  Aledica.  .  .  .  One  of  the 
most  valuable  works  in  the  language  on  the  subjects 
of  which  it  treats. — N.  Y.  Med.  Joxirnal,  Oct.  1868. 

The  rapid  exhaustion  of  two  editions  of  Prof.  Still6'B 
scholarly  work,  and  the  consequent  neces^ity  for  a 
third  edition,  is  sufficient  evidence  of  the  high  esti- 
mate placed  upon  it  by  the  profession.  It  is  no  exag- 
geration to  say  that  there  is  no  superior  work  upon 
the  subject  in  the  English  language.  The  present 
edition  is  fully  up  to  the  most  recent  advance  in  the 
science  and  art  of  therapeutics. — Leavenworth  Medi- 
cal Herald,  Aug.  1S6S. 

The  work  of  Prof.  Still6  has  rapidly  taken  a  high 
place  in  professional  esteem,  and  to  say  that  a  third 
edition  is  demanded  and  now  appears  before  us,  suffi- 
ciently attests  the  firm  position  this  treatise  has  made 
for  itself.  As  a  work  of  great  research,  and  scholar- 
ship, it  is  safe  to  say  we  have  nothing  superior.  It  is 
exceedingly  full,  and  the  busy  practitioner  will  find 
ample  suggestions  upon  almost  every  important  point 
of  therapeutics. — Cincinnati  Lancet,  Aug.  1868. 


/GRIFFITH  {ROBERT  E.),  M.D. 

A  UNIVERSAL  FORMULARY,  Containing  the  Methods  of  Pre- 
paring and  Administering  OflBcinal  and  other  Medicines.  The  whole  adapted  to  Physicians 
and  Pharmaceutists.  Second  edition,  thoroughly  revised,  with  numerous  additions,  by 
KoBERT  P.  Thomas,  M.D.,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of 
Pharmacy.  In  one  large  and  handsome  octavo  volume  of  650  pages,  double-columns. 
Extra  cloth,  $4  00;  leather,  $5  00. 

Three  complete  and  extended  Indexes  render  the  work  especially  adapted  for  immediate  consul- 
tation. One,  of  Diseases  and  their  Remedies,  presents  under  the  head  of  each  disease  the 
remedial  agents  which  have  been  usefully  exhibited  in  it,  with  reference  to  the  formulae  containing 
them — while  another  of  Pharmaceutical  and  Botanical  Names,  and  a  very  thorough  Genbrai, 
Index  afford  the  means  of  obtaining  at  once  any  information  desired.  The  Formulnry  itself  is 
arranged  alphabetically,  under  the  heads  of  the  leading  constituents  of  the  prescriptions. 

We  know  of  none  in  our  language,  or  any  other,  so  comprehensive  in  its  details. — London  Lancet. 

One  of  the  most  complete  works  of  the  kind  in  any  language. — Edinhur$h  Med.  Journal. 

We  are  not  cognizant  of  the  existence  of  a  parallo  work. — London  Med.  Guietts. 


Henry  C.  Lea's  Publications— ( 1/a/!.  Med.  and  Therupeufics).       13 


p  ERE  IRA  [JONATHAN),  M.D.,  F.  R.S.  and  L.S. 

MATERIA   MEDICA    AND  THERAPEUTICS;   being  an  Abrido. 

ment  of  the  late  Dr.  Pereira's  Elements  of  Materia  Medica,  arranged  in  conformity  with 
the  British  Pharmacopoeia,  and  adapted  to  the  use  of  Medical  Practitioners,  Chemists  and 
Druggists,  Medical  and  Pharmaceutical  Students,  <fce.  By  F.  J.  Parre,  M.D.,  Senior 
Physician  to  St.  Bartholomew's  Hospital,  and  London  Editor  of  the  British  Pharmacopoeia  j 
assisted  by  Robert  Bentlei-,  M.R.C.S.,  Professor  of  Materia  Medica  and  Botany  to  the 
Pharmaceutical  Society  of  Great  Britain;  and  by  Robert  Warington,  F.R.S.,  Chemical 
Operator  to  the  Society  of  Apothecaries.  With  numerous  additions  and  references  to  the 
United  States  Pharmacopoeia,  by  Horatio  C.  Wood,  M.D.,  Professor  of  Botany  in  the 
University  of  Pennsylvania.  In  one  large  and  handsome  octavo  volume  of  1040  closely 
printed  pages,  with  2M  illustrations,  extra  cloth,  $7  00 ;  leather,  raised  bands,  $8  00 
The  task  of  the  American  editor  has  evidently  been 

no  sinecure,  lor  not  only  has  he  given  to  us  all  that 

is  contained  in  the  abridgment  useful  for  our  pur- 


poses, but  by  a  careful  aud  judicious  embodiment  of 
over  a  hundred  new  remedies  has  increased  the  size 
of  the  former  work  fully  one-third,  besides  adding 
many  new  illustrations,  some  of  which  are  original. 
We  utiheisitatingly  say  that  by  so  doing  he  has  pro- 
portionately increased  the  value,  not  only  of  the  con- 
densed edition,  but  has  extended  the  applicability  of 
the  great  original,  and  has  placed  his  medical  coun- 
trymen under  lasting  obligetious  to  him.  The  Ame- 
rican physician  now  has  all  that  is  needed  in  the 
shape  of  a  complete  treatise  on  materia  medica,  and 
the  medical  student  has  a  text-book  which,  for  prac- 
tical utility  and  intrinsic  worth,  stands  unparalleled. 
Although  of  considerable  size,  it  is  none  too  large  for 
the  purposes  for  which  it  has  been  intended,  and  every 
niedical  man  should,  in  justice  to  himself,  spare  a 
place  for  it  upon  his  book-shelf,  resting  assured  that 
the  more  he  consults  it  the  better  he  will  be  satisfied 
of  its  excellence. — N.  Y.  Med.  Rp.eord,  Nov.  13,  1S66. 

It  will  fill  a  place  which  no  other  work  can  occupy 
Iji  the  library  of  the  physician,  student,  and  apothe- 
eary. — Boston  Med.  and  Surg.  Journal,  Nov.  8,  1866. 

Of  the  many  works  on  Materia  Medica  which  have 
appeared  since  the  issuing  of  the  British  Pharmaco- 


poeia, none  will  be  more  acceptable  to  the  student 
and  practitioner  than  the  present.  Pereira's  Materia 
Medica  had  long  ago  asserted  for  itself  the  position  of 
being  the  most  complete  work  on  the  subject  in  the 
English  language.  But  its  very  completeness  stood 
in  the  way  of  its  success.  Except  in  the  way  of  refer- 
ence, or  to  those  who  made  a  special  study  of  Materia 
Medica,  Dr.  Pereira's  work  was  too  full",  and  its  pe- 
rusal required  an  amount  of  time  which  few  had  at 
their  disposal.  Dr  Farre  has  very  judiciously  availed 
himself  of  the  opportunitv  of  the  publication  of  the 
new  Pharmacopojia,  dybrin2:ing  out  an  abridged  edi- 
tion of  the  great  work.  This  edition  of  Pereira  is  by 
no  means  a  mere  abridged  re-issue,  but  contains  many 
improvements,  both  in  the  descriptive  and  thera- 
peutical departments.  We  can  recommend  it  as  a 
very  excellent  and  reliable  text-book. — Edinburgh 
Med.  Journal,  February,  1866. 

The  reader  cannot  fail  to  be  impressed,  at  a  glance, 
with  the  exceeding  value  of  this  work  as  a  compend 
of  nearly  all  useful  knowledge  on  the  materia  medica. 
We  are  greatly  inrtshted  to  Professor  Wood  for  his 
adaptation  of  it  to  our  meridian.  Without  his  emen- 
dations and  additions  it  would  lose  much  of  its  value 
to  the  American  student.  With  them  it  is  an  Ameri- 
can book.  — Paei/Ze  Medical  and  Surgical  Journal, 
December,  1866. 


fjLLIS  [BENJAMIN),  M.D. 

THE  MEDICAL  FORMULARY:  being  a  Collection  of  Prescriptions 

derived  from  the  writing!?  and  practice  of  many  of  the  most  eminent  physicians  of  America 
and  Europe.    Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poisons.    The 
whole  accompanied  with  a  fevr  brief  Pharmaceutic  and  Medical  Observations.    Twelfth  edi- 
tion, carefully  revised  and  much  improved  by  Albert  H.  Smith,  M.D.    In  one  volume  8v^. . 
of  376  pages,  extra  cloth,  %^i  00.      {Lately  Puhlished.) 
This  work  has  remained  for  some  time  out  of  print,  owing  to  the  anxious  care  with  which  the 
Editor  has  sought  to  render  the  present  edition  worthy  a  continuance  of  the  very  remarkable 
favor  which  has  carried  the  volume  to  the  unusual  honor  of  a  Twelfth  Edition.     He  has  sedu- 
lously endeavored  to  introduce  in  it  all  new  preparations  and  combinations  deserving  of  confidence, 
besides  adding  two  new  classes,  Antemetics  and  Disinfectants,  with  brief  references  to  the  inhalation 
©f  atomized  fluids,  the  nasal  douche  of  Thudichum,  suggestions  upon  the  method  of  hypodermic 
injection,  the  administration  of  anaBsthetics,  Ac.  &c.     To  accommodate  these  numerous  additions, 
he  has  omitted  much  which  the  advance  of  science  has  rendered  obsolete  or  of  minor  importance, 
notwithstanding  which  the  volume  hiiB  been  increased  by  more  than  thirty  pages.     A  new  feature 
will  be  found  in  a  copious  Index  of  Diseases  and  their  remedies,  which  cannot  but  increase  the 
value  of  the  work  as  a  suggestive  book  of  reference  for  the  working  practitioner.    Every  precaution 
has  been  taken  to  secure  the  typographical  accuracy  so  nece.'^sary  in  a  work  of  this  nature,  and  it 
i.i  hoped  that  the  new  edition  will  fully  maintain  the  position  which  "  Ellis'  Formulary''  has 
long  occupied. 


(1  ARSON  [JOSEPH),  M.D., 

'-^  Prnfensor  of  Materia  Medica,  and  Pharmacy  in  the  University  of  Pennsylvania,  Sec. 

SYNOPSIS  OF  THE   COURSE   OF   LECTURES   OX  MATERIA 

MEDICA  AND  PHARMACY,  delivered  in  the  University  of  Pennsylvania.  With  three 
Lectures  on  the  Modus  Operandi  of  Medicines.  Fourth  and  revised  edition,  extra  cloth. 
$3  00. 


EUNGLISON'S  NEW  REMEDIES.  WITH  FORMITL^ 
FOR  THEIR  PREPARATION  AND  ADMINISTRA- 
TION Seventh  edition,  with  extensive  additions. 
One  vol.  8vo.,  pp.  770;  -extra  cloth.    %V  00. 

ROTLE'S  MATERIA  MEDICA  AND  THERAPEU- 
TICS. Edited  by  Joseph  Caeson,  M.  D.  With 
ninety-eight  illustrations.  1  vol.  Svo.,  pp.  700,  ex- 
tra cloth.     %■^  00. 

CHRISTISON'S  DISPENSATORY.  With  copious  ad- 
ditions, and  213  large  wood-engravings.     By  E 


EOLESFELD  GRIFFITH,  M.  D.  One  vol.  8vo.,  pp.  1000 ; 
extra  cloth.     *4  00. 

CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  OP 
Ai.noHOLic  Liquors  in  Hualth  and  Disf.ase.  New 
edition,  with  a  Preface  by  D.  F.  Condie,  M  D.,  and 
explanations  of  scientific  words.  In  one  neat  12mo. 
volume,  pp.  I7S,  extra  cloth.     60  cents. 

De  JONGH  on  THE  THREE  KINDS  OF  COD-LIVEB 
Oil,  with  their  Chemical  and  Therapeutic  Pro- 
perties    1  vol.  12mo.,  cloth.    75  cents. 


14 


Henry  C.  Lea's  Publications— (Pa^^oZogry,  &c.) 


pREEN  [T.  HENRY),  M.D., 

^  Lecturer  on  Pathology  and  Morbid  Anatomy  at  Charing-Cross  Hospital  Medical  School. 

PATHOLOGY  AND  MORBID  ANATOMY.     With  numerous  Hlus- 

trations  on  Wood.     In  one  very  handsome  octavo  volume  of  over  250  pages,  extra  cloth, 

$2  50.     {Lately  Published.) 

The  scope  and  object  of  this  volume  can  be  gathered  from  the  following  condensed 

We  have  been  very  much  pleased  by  our  perusal  of  1  thologyand  morbid  anatomy.  The  author  shows  that 

this  little  volume     It  is  the  only  one  of  the  kind  with     he  has  been  not  only  a  student  of  the  teachings  of  his 

which  we  are  acquainted,  and  practitioners  as  well     confrire.9  in  this  branch  of  science,  but  a  practical 

as  students  will  find  it  a  very  useful  guide;  for  the     and  conscientious  laborer  in  the  post-mortem  chain- 


information  is  up  to  the  day,  well  and  compactly  ar- 
ranged, without  being  at  all  sca.D.lj.— London  Lan- 
cet, Oct.  7,  1871. 

It  embodies  in  a  comparatively  small  space  a  clear 
statement  of  the  present  state  of  our  knowledge  of  pa- 


ber.  The  work  will  prove  a  useful  one  to  the  great 
mass  of  students  and  practitioners  whose  time  for  de- 
votion to  this  class  of  studies  is  limited.  — Am.  Juuri}. 
of  Syphilographtj,  April,  1S72. 


GLUGE'S  ATLAS  OF  PATHOLOGICAL  HISTOLOGY. 

Translated,  with  Notes  and  Additions,  by  Joseph 
Letdy,  M.  D.  In  one  volume,  very  large  imperial 
quarto,  with  320  copper-plate  figures,  plain  and 
colored,  extra  cloth.     $4  00. 

SIMON'S  GENERAL  PATHOLOGY,  as  conducive  to 
the  Establishment  of  Rational  Principles  for  th«s 
Prevention  and  Cure  of  Disease.  In  one  octavo 
volume  of  212  pages,  extra  cloth.     $1  2.i. 

SOLLY  ON  THE  HUMAN  BRAIN  ;  its  Structure, Phy- 
siology, and  Diseases.  From  the  Second  and  much 
enlarged  London  edition.  In  one  octavo  volume  of 
."iOO pages, with  120 wood-cuts;  extra   cloth.    $2  50. 

LA  ROCHE  ON  YELLOW  FEVER,  considered  in  its 
Historical,  Pathological,  Etiological,  and  Therapeu- 


tical Relations.   In  two  large  and  handsome  octavo 
volumes  of  nearly  1.500  pages,  extra  cloth.     $7  00. 

HOLLAND'S  MEDICAL  NOTES  ANI  REFLEC- 
TIONS.    1  vol.  Svo.,  pp.  500,  extra  cloth.    $3  50. 

WHAT  TO  OBSERVE  AT  THE  BEDSIDE  AND  AFTER 
De.^th  in  Medical  Cases.  Published  under  the 
authority  of  the  London  Society  for  Medical  Obser- 
vation. From  the  second  London  edition.  1  vol. 
royal  12mo.,  extra  cloth.     $1  00. 

LAYCOCK'S  LECTURES  ON  THE  PRINCIPLES 
A.vD  Methods  of  Medical  Observation  a.sd  Re- 
search. For  the  use  of  advanced  students  and 
junior  practitioners.  In  one  very  neat  royal  12mo. 
volume,  extra  cloth.    $1  00. 


r^ROSS  {SAMUEL  D.),  M.  D., 

v-^  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

ELEMENTS    OF    PATHOLOGICAL   ANATOMY.     Third    edition, 

thoroughly  revised  and  greatly  improved.  In  one  large  and  very  handsome  octavo  volume 
of  nearly  800  pages,  with  about  three  hundred  and  fifty  beautiful  illustrations,  of  which  a 
large  number  are  from  original  drawings  J   extra  cloth.     $4  00. 

TONES  {a  HAND  FIELD),  F.R.S.,  and  SI  EV  EKING  {ED.  H),  M.D., 

*-J  Assistant  Physicians  and  Lecturers  in  St.  Mary's  Hosjiital. 

A  MANUAL  OF   PATHOLOGICAL  ANATOMY.     First  American 

edition,  revised.  With  three  hundred  and  ninety-seven  handsome  wood  engravings.  In 
one  large  and  beautifully  printed  octavo  volume  of  nearly  750  pages,  extra  cloth,  $3  50. 


B 


ARCLAY  {A.  W.),  M.  D. 

A  MANUAL  OF  MEDICAL  DIAGNOSIS;  being  an  Analysis  of  the 

Signs  and  Symptoms  of  Disease.     Third  American  from  the  second  and  revised  London 
edition.     In  one  neat  octavo  volume  of  451  pages,  extra  cloth.     $3  60. 


D 


IJnLLIAMS  {CHARLES  J.  B.),  M.D., 

'  '  Professor  of  Clinical  Medicine  in  University  College,  London. 

PRINCIPLES  OF  MEDICINE.     An  Elementary  Yiew  of  the  Causes, 

Nature,  Treatment,  Diagnosis,  and  Prognosis  of  Disease;  with  brief  remarks  on  Hygienics, 
or  the  preservation  of  health.  A  new  American,  from  the  third  and  revised  London  edition. 
In  one  octavo  volume  of  about  500  pages,  extra  cloth.     $3  60. 

DNGLISON,  FORBES,  TWEEDIE,  AND   CONOLLY. 

THE  CYCLOPAEDIA  OF   PRACTICAL  MEDICINE:    comprising 

Treatises  on  the  Nature  and  Treatment  of  Diseases,  Materia  Medica  and  Therapeutics, 
Diseases  of  Women  and  Children,  Medical  Jurisprudence,  &o.  &c.  In  four  large  super-royal 
octavo  volumes,  of  3254  double-columned  pages,  strongly  and  handsomely  bound  in  leather, 
$16  ;  extra  cloth.     $11. 

*^*  This  work  contains  no  less  than  four  hundred  and  eighteen  distinct  treatises,  contributed 
by  sixty-eight  distinguished  physicians. 

pox  ( WILSON),  M.D., 

-*■  holme  Prof  of  Clinical  Med.,  University  Coll.,  London. 

THE  DISEASES  OF  THE  STOMACH:  Being  the  Third  Edition  of 

the  "Diagnosis  and  Tre.Ttment  of  the  Varieties  of  Dyspepsia."  Revised  and  Enlarged. 
With  illustrations.     In  one  handsome  octavo  volume.      (In  Press.) 

The  present  edition  of  Dr.  Wilson  Fox's  very  admi-  j  Dr.  Fox  has  put  f.irth  a  volume  of  uncommon  ex- 
rable  work  differs  from  the  preceding  in  that  it  deals  ;  cellence,  which  we  feel  very  sure  will  take  a  high 
with  other  maladies  than  dyspepsia  only. — London  |  rank  among  works  that  treat  of  the  stomach.— 4jn. 
Med.  Times,  Feb.  8,  1873.  |  Practitioner,  March,  1S73. 


Henry  C.  Lea's  Publications — {Practice  of  Medicine).  15 

TfLINT  (AUSTIN),  M.D., 

-*■  Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Med.  College,  N  T 

A   TREATISE    OX    THE    PRINCIPLES    AXD    PRACTICE    OP 

MEDICINE  ;  designed  for  the  use  of  Students  and  Practitioners  of  Medicine.  Fourth 
edition,  revised  and  enlarged.  In  one  large  and  closely  printed  octavo  volume  of  about  1100 
pages;  handsome  extra  cloth,  $6  00;  or  strongly  bound  in  leather,  with  raised  bands,  $7  00. 
(Nearly  Ready.) 

By  common  consent  of  the  English  and  American  medical  press,  this  work  has  been  assigned 
to  the  highest  position  as  a  complete  and  compendious  text-book  on  the  most  advanced  condition 
of  medical  science.  At  the  very  moderate  price  at  which  it  is  offered  it  will  be  found  one  of  the 
cheapest  volumes  now  before  the  profession. 


Admirable  and  uaequalled.  —  Western  Journal  of 
Medicine,  Nov.  1S69. 

Dr.  Flint's  work,  though  claiming  no  higher  title 
than  that  of  a  text-book,  is  really  more.  He  is  a  man 
of  large  clinical  experience,  and  his  book  is  full  of 
such  masterly  descriptions  of  disease  as  can  only  be 
drawn  by  a  man  intimately  acquainted  with  their 
various  forms.  It  is  not  so  long  since  we  had  the 
pleasure  of  re^'iewiug  his  first  edition,  and  we  recog- 
nize a  great  improvement,  especially  in  the  general 
part  of  the  work.  It  is  a  work  which  we  can  cordially 
recommend  to  our  readers  as  fully  abreast  of  the  sci- 
ence of  the  day. — Edinburgh  Med.  Journal,  Oct.  '69. 

One  of  the  best  works  of  tlie  kind  for  the  practi- 
tioner, and  the  most  convenient  of  all  for  the  student. 
— Am.  Journ.  Med.  Sciences,  Jan.  1S69. 

This  work,  which  stands  pre-eminently  as  the  ad- 
rance  standard  of  medical  science  up  to  the  present 
time  in  the  practice  of  medicine,  has  for  its  author 
one  who  is  well  and  widely  known  as  one  of  the 
leading  practitioners  of  this  continent.  In  fact,  it  is 
seldom  that  any  work  is  ever  issued  from  the  press 
more  deserving  of  universal  recommendalioa. — Do- 
niinio7i  Med.  Journal,  May,  1869. 

The  third  edition  of  this  most  excellent  book  scarce- 
ly needs  any  commendation  from  us.  The  volume, 
8.S  it  stands  now,  is  really  a  marvel :  first  of  all,  it  is 


sxcellently  printed  and  bound — and  we  encounter 
that  ^luxury  of  America,  the  ready-cut  pages,  which 
the  Yankees  are  'cute  enough  to  insist  upon — nor  are 
these  by  any  means  trifles  ;  but  the  contents  of  the 
book  are  astonishing.  Not  only  is  it  wonderful  that 
iny  one  man  can  h.-\  ve  grasped  in  his  mind  the  whole 
scope  of  medicine  with  that  vigor  which  Dr.  Flint 
ihows,  but  the  condensed  yet  clear  way  in  which 
this  is  done  is  a  perfect  literary  triumph  Dr.  Flint 
;s  pre-eminently  one  of  the  strong  men,  whose  right 
to  do  this  kind  of  thing  is  well  admitted  ;  and  we  say 
10  more  than  the  truth  when  we  affirm  that  he  is 
very  nearly  the  only  living  man  that  could  do  it  with 
such  results  as  the  volume  before  us. — The  London 
Practitioner,  March,  1S69. 

This  is  in  some  respects  the  best  text-book  of  me'di- 
cine  in  our  language,  and  it  is  highly  appreciated  on 
the  other  side  of  the  Atlantic,  inasmuch  as  the  first 
edition  was  exhausted  in  a  few  months.  The  second 
adition  was  little  more  than  a  reprint,  but  the  present 
Has,  as  the  author  says,  been  thoroughly  revised. 
Much  valuable  matter  has  been  added,  and  by  mak- 
ing the  type  smaller,  the  bulk  of  the  volume  is  not 
much  increased.  The  weak  point  in  many  Auieiicaa 
Works  is  pathology,  but  Dr.  Flint  has  taken  peculiar 
pains  on  this  point,  greatly  to  the  value  of  the  book. 
— London  Med.  Times  and  Oazette,  Feb.  6,  1869. 


BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  Additions  by  D.  F.  Condie, 
M.  D.     1  vol.  Svo.,  pp.  600,  cloth.     $2  50. 


TODD'S  CLINICAL  LECTURES  ON  CERTAIN  ACUTE 
Diseases.  In  one  neat  octavo  volume,  of  320  pages, 
extra  cloth.    $2  50. 


F 


4  VF  [F.  W.),  M.  D.,  F.  R.  S., 

Senior  Asst.  Physician  to  and  Lecturer  on  Physiology,  at  Gxiy^s  Hospital,  &c. 

A  TREATISE  ON  THE    FUNCTION  OF  DIGESTION;  its  Disor- 

ders  and  their  Treatment.     From  the  second  London  edition.     In  one  handsome  volume, 
small  octavo,  extra  cloth,  $2  00.      {Lately  Published.) 


The  work  before  us  is  one  which  deserves  a  wide 
circulation.  We  know  of  no  better  guide  to  the  study 
of  digestion  and  its  disorders. — St.  Louii  Med.  and 
Surg.  Journal,  July  10,  1869. 

A  thoroughly  good  book,  being  a  careful  systematic 


treatise,  and  sufficiently  exhaustive  for  all  practical 
purposes. — Leavenworth  Med.  Herald,  July,  1869. 

A  very  valuable  work  on  the  subject  of  which  it 
treats.  Small,  yet  it  is  full  of  valuable  information. 
— Cincinnati  Med.  Sepertm-y,  Jane,  1869. 


nRINTON  (WILLIA31),  M.D.,  F.R.S. 
'^LECTURES  ON  THE  DISEASES  OF  THE   STOMACH;   with  an 

Introduction  on  its  Anatomy  and  Physiology.  From  the  second  and  enlarged  London  edi- 
tion. With  illustrations  on  wood.  In  one  handsome  octavo  volume  of  about  300  pages, 
extra  cloth.     $3  25. 


flHAMBERS  ( T.  K.),  M.  D., 

vy  Consulting  Physician  to  St.  Mary's  Hospital,  London,  &e. 

THE  INDIGESTIONS ;  or,  Diseases  of  the  Digestive  Organs  Functionally 

Treated.    Third  and  revised  Edition.    In  one  handsome  octavo  volume  of  383  pages,  extra 
cloth.     $3  00.      {Lately  Published.) 

merit,  we  know  of  no  more  desirable  acquisition  to 
a  physician's  library  than  the  book  before  us.  He 
who  should  commit  its  contents  to  his  memory  would 
tiud  its  price  an  investment  of  capital  that  returned 
him  a  most  usurious  rate  of  interest. — N.  Y.  Medical 


So  very  large  a  proportion  of  the  patients  applying 
to  every  general  practitioner  sutler  from  some  form 
of  indigestion,  that  whatever  aids  him  in  their  man- 
agement directly  "puts  money  in  his  purse,"  and  in- 
directly does  more  than  auytliing  else  to  advance  his 
reputation  with  the  public.  From  this  purely  mate- 
rial point  of  view,  setting  aside  its  higher  claims  to 


Gazette,  Jan.  28,  1871. 


JDY  THE  SAME  AUTHOR.     {Lately  Published) 

RESTORATIVE  MEDICINE.     An  Harveian  Annual  Oration,  deliv- 

ered  at  the  Royal  College  of  Physicians,  London,  on  June  24,  1871.     With  Two  Sequels. 
In  one  very  handsome  volume,  small  12mo.,  extra  cloth,  $1  00. 


16 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


rTARTSHORNE  [HENRY).  31. D., 

-O  Profesi-or  of  ffi/giene  in  tlie  Univer-tity  of  Pe.nnsylvania. 

ESSENTIALS  OF  THE   PRINCIPLES  AND   PRACTICE  OF  MEDI- 

CINE.     A  handy-book  for  Students  and  Practitioners.     Third  edition,  revised  and  im- 
proved.    In  one  handsome  i-oyal  J2mo.  volume  of  487  pages,  clearly  printed  on  small  type, 
cloth,  $2  38;  half  bound,  $2  63.      (Now  Etady.) 
The  very  remarkable  favor  which  has  been  bestowed  upon  this  work,  as  manifested  in  the  ex- 
haustion of  two  large  editions  within  four  years,  shows  that  it  has  successfully  supplied  a  want 
felt  by  both  student  and  practitioner  of  a  volume  which  at  a  moderate  price  and  in  a  convenient 
size  should  afford  a  clear  and  compact  view  of  the  most  modern  teachings  in  medical  practice. 
In  preparing  the  work  for  a  third  edition,  the  author  has  sought  to  maintain  its  character  by  very 
numerous  additions,  bringing  it  fully  up  to  the  science  of  the  day,  but  so  concisely  framed  that 
the  size  of  the  volume  is  increased  only  by  thirty  or  forty  pages.     The  extent  of  the  new  informa- 
tion thus  introduced  may  be  estimated  by  the  fact  thai  there  have  been  two  hundred  and  sixty 
separate  additions  made  to  the  text,  containing  references  to  one  hundred  and  eighty  new  authors. 
This  little  epitome  of  medical  knowledge  has  al-  j  mulas  are  appended,  intended  as  examples  merely, 
ready  been  noticed  by  lis.     It  is  a  vade  mecum  of;  nut  as  guides  for  unthinking  practitinuers.     A  com- 
value   including  in  a  short  space  most  of  what  is  es-  '  plete  index  facilitates  the  use  of  this  little  volume,  ia 
sentia'l  in  the  science  and  practice  of  medicine.     The     which  all  important  remedies  lately  introduced,  such 
third  edition  is  well  up   to  the   present  day  in  the  '  as  chloral  hydraie  and  carbolic  acid,  have  received 
modern  methods  of  treatment,  and  in  the  use  of  newly  i  their  full  share  of  attention. — Am.  Journ.  nf  Pharm., 
discovered  Atugi.— Boston  Med.  and  Sarg.  Journal,  |  Nov.  1871. 
Oct.  19,  1S71. 

Certainly  very  few  volumes  contain  so  much  pre 
cise  information  within  so  small  a  compass. 


-N.  Y. 
ilp.d.  Journal,  Nov.  1871 

The  diseases  are  conveniently  classified;  symptoms, 
causation,  diagnosis,  prognosis,  and   treatment   are 

carefully  considered,   the  whole   being  marked    by  ,  demand. — Cincinnati  Med.  Repertory,  Nov.  1871. 
briefness,  but  clearness  of  expression.     Over  2.50  for- 


It  is  an  epitome  of  the  whole  science  and  practice 
of  medicine,  and  will  be  found  most  valuable  to  the 
practitioner  for  easy  reference,  and  especially  to  the 
student  in  attendance  upon  lectures,  whose  time  is 
too  much  occupied  with  many  studies,  to  con.sult  the 
larger  works.     Such  a  work  must  always  be  in  great 


OF 


l^ATSON  (THOMAS),  M.  D.,  ifc. 

LECTURES     ON    THE     PRINCIPLES    AND    PRACTICE 

PHYSIC.     Delivered  at  King's  College,  London.     A  new  American,  from  the  Fifth  re- 
vised and  enlarged  English  edition.     Edited,   with  additions,  and  several  hundred  illus- 
trations, by  Henry  Hartshorne,  M.D.,  Professor  of  Hygiene  in  the  University  of  Penn- 
sylvania.  In  two  large  and  handsome  8vo.  vols.   Cloth,  $9.00  ;  leather,  $1 1  00.    {Just re'ii/7/.) 
With  the  assistance  of  Professor  George  Johnson,  his  successor  in  the  chair  of  Practice  of  Medi- 
cine in  King's  College,  the  author  has  thoroughly  revised  this  work,  and  has  sought  to  bring  it 
on  a  level  with  the  most  advanced  condition  of  the  -ubject.     As  he  himself  remarks  :   "Consider- 
ing the  rapid  advance  of  medical  science  during  the  last  fourteen  years,  the  present  edition  would 
be  worthless,  if  it  did  not  differ  much  from  the  last" — but  in  the  extensive  alterations  and  addi- 
tions that  have  been  introduced,  the  effort  of  the  author  h.as  been  to  retain  the  lucid  and  collo- 
quial style  of  the  lecture-room,  which  has  made  the  work  so  deservedly  popular  with  all  classes 
of  the  profession.    Notwithstanding  these  changes,  there  are  some  subjects  on  which  the  American 
reader  might  reasonably  expect  more  detailed  information  than  has  been  thought  requisite  in 
England,  and  these  deficiencies  the  editor  has  endeavored  to  supply. 

The  large  size  to  which  the  work  has  grown  seems  to  render  it  necessary  to  print  it  in  two  vol- 
umes, in  place  of  one,  as  in  the  last  American  edition.  It  is  therefore  presented  in  that  shape, 
handsomely  printed,  at  a  very  reasonable  price,  and  it  is  hoped  that  it  will  fully  maintain  the 
position  everywhere  hitherto  accorded  to  it,  of  the  standard  and  classical  representative  of  Eng- 
lish practical  medicine. 


At  length,  after  many  months  of  expectation,  we 
have  the  satisfaction  of  finding  ourselves  this  week  in 
possession  of  a  revised  and  enlarged  edition  of  Sir 
Tliomas  Watson's  celebrated  Lectures  It  is  a  sub- 
ject for  congratulation  and  for  thankfulness  that  Sir 
Thomas  Watson,  during  a  period  of  comparative  lei- 
sure, after  a  long,  laborious,  and  most  honorable  pro- 
fessional career,  while  retaining  full  possession  of  his 
high  mental  faculties,  should  have  employed  the  op- 
portunity to  submit  his  Lectures  to  a  more  thorough 
revision  than  was  possible  during  the  earlier  and 
busier  period  of  his  life.  Carefully  passing  in  review 
some  of  the  most  intricate  and  important  pathological 
and  practical  questions,  the  results  of  his  clear  insight 
and  his  calm  judgment  are  now  recorded  for  the  bene- 
fit of  mankind,  in  language  which,  for  precision,  vigor, 
and  cla.'isical  elegance,  has  rarely  been  equalled,  and 
never  surpassed  The  revision  has  evidently  been 
most  carefully  done,  and  the  results  appear  in  almost 
every  page. — Brit.  Med.  Journ.,  Oct.  14,  1871. 

No  words  can  convey  the  pleasurable  satisfaction 
that  we  feel  in  looking  over  the  revised  edition  of 
the  admirable  lectures  of  this  distinguished  author. 
The  earnestness  which  marked  his  whole  profes- 
sional career  leads  him,  in  a  characteristic  manner, 
to  devote  his  last  leisure  hours  to  the  correction  of  his 
great  classic  work.  The  lectures  are  so  well  known 
and  so  justly  appreciaied,  that  it  is  scarcely  neces- 
s:H,iy  to  do  more  than  call  attention  to  the  special 
advantages  of  the  last  over  previous  editions.  In 
the  revision,  the  author  has  displayed  all  the  charms 
and  advantages  of  great  culture  and  a  ripe  experi- 
ence combined  with  the  soundest  judgment  and  sin- 


cerity of  purpose.  The  author's  rare  combination 
of  great  scientific  attainments  combined  with  won- 
derful forensic  eloquence  has  exerted  extraordinary 
inlluence  over  the  last  two  generations  of  physicians. 
His  clinical  descriptions  of  most  diseases  have  never 
been  eciualled  ;  and  on  this  score  at  least  his  work 
will  live  long  in  the  future.  The  work  will  be 
sought  by  all  who  appreciate  a  great  book. — Amer. 
Journal  of  Syphilogrnijhy,  July,  1872.: 

We  are  exceedingly  gratified  at  the  reception  of 
this  new  edition  of  Watson,  pre-eminently  the  prince 
of  English  author.s,  on  "Practice."  We,  who  read 
the  first  edition  as  it  came  to  us  tardily  and  in  frag- 
ments through  the  "Medical  News  and  Library," 
shall  never  forget  the  great  pleasure  and  profit  we 
derived  from  its  graphic  delineations  of  disease,  its 
vigorous  style  and  splendid  English.  Maturity  of 
years,  extensive  observation,  profound  research, 
and  yet  continuous  enthusiasm,  have  combined  to 
give  us  in  this  latest  edition  a  model  of  professional 
excellence  in  teaching  with  rare  beauty  in  the  mode 
of  communication.  But  this  classic  needs  no  eulo- 
giura  of  ours.  The  selection  of  Prof.  Hartshorne  as 
the  American  editor,  is  to  us  peculiarly  gratifying, 
and  must  insure  even  larger  popularity  and  more 
general  sale  to  American  readers.  Eveiy  guarantee 
is  thus  afforded  that  in  every  part  the  book  will  be 
found  up  to  the  times.  Will  it  do  to  repeat  the  re- 
mark we  have  seen  somewhere:  "  No  library  can  be 
considered  complete  without  it?"  Although  the 
phrase  may  not  savor  of  originality,  it  is,  neverthe- 
less, most  emphatically  true. — Chicago  Med.  Juurn., 
July,  1872. 


Henry  C.  Lea's  Publications — (Diseases  of  Lungs  and  Heart).     It 


PLINT  {AUSTIN),  31. D., 

•*•  Priifes>ior  nf  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Med.  College,  N.  T. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OP  DISEASES  OF   THE  HEART.     Second  revised  and  enlarged 

edition.     In  one  octavo  volume  of  560  pages,  with  a  plate,  extra  cloth,  $4.     (Just  Issued.) 

The  author  has  sedulously  improved  the  opportunity  aiforded  him  of  revising  this  work.   Portions 

of  it  have  been  rewritten,  and  the  whole  brought  up  to  a  level  with  the  most  advanced  condition  of 

science.  It  must  therefore  continue  to  maintain  its  position  as  the  standard  treatise  on  the  subject. 

Ur.  Fliut  chose  a  difflcult  subject  for  his  researches,  i  able  for  purposes  of  illustration,  in  connection  with 


and  has  sliown  remarkable  powers  of  observation 
and  reflection,  as  well  as  great  industry,  in  his  treat- 
ment of  it.  His  book  must  be  considered  the  fullest 
and  clearest  practical  treatise  on  those  subjects,  and 
should  be  in  the  hands  of  all  practitioners  and  stu- 
dents. It  is  a  credit  to  American  medical  literature. 
— Amer.  Journ.  of  the  Med.  Sciences,  July,  1S60. 

We  question  the  fact  of  any  recent  American  author 
In  our  profession  being  more  extensively  known,  or 
more  deservedly  esteemed  in  this  country  than  Dr. 
Flint.  We  willingly  acknowledge  his  success,  more 
particularly  in  the  volume  on  diseases  of  the  heart, 
in  making  an  extended  personal  clinical  study  avail- 


cases  which  have  been  reported  by  other  trustworthy 
observers. — Brit,  and  Fur.  Med.-Chirurg,  Review. 

In  regard  to  the  merits  of  the  work,  we  have  no 
hesitation  in  pronouncing  it  full,  accurate,  and  judi- 
cious. Considering  the  present  state  of  .science,  such 
a  work  was  much  needed.  It  should  be  in  the  hands 
of  every  practitioner. — Chicago  Med.  Journ. 

With  more  than  pleasure  do  we  hail  the  advent  of 
this  work,  for  it  tills  a  wide  gap  on  the  list  of  text- 
books for  ourschools,  and  is,  for  the  practitioner,  the 
most  valuable  practical  work  of  its  kind. — N.  0.  Med. 
News. 


B 


r  THE  SAME  AUTHOR. 

PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OP  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFPECTINa  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  595  pages,  extra  cloth,  $4  60. 

which  pervades  his  whole  work  lend  an  additional 
force  to  its  thoroughly  practical  character,  which 
cannot  fail  to  obtain  for  it  a  place  as  a  standard  work 
on  diseases  of  the  respiratory  system. — London 
Lancet,  Jan.  19,  1S67. 

This  is  an  admirable  book.  Excellent  in  detail  and 
execution,  nothing  better  could  be  desired  by  tbe 
practitioner.  Dr.  Flint  enriches  his  subject  with 
much  solid  and  not  a  little  original  observation. — 
Ranking's  Abstract,  Jan.  1867. 


Dr.  Flint's  treatise  is  one  of  the  most  trustworthy 
guides  which  he  can  consult.  The  style  is  clear  and 
distinct,  and  is  also  concise,  being  free  from  that  tend- 
ency to  over-refinement  and  unnecessary  minuteness 
which  characterizes  many  works  on  the  same  suh- 
iec.t.— Dublin  Medical  Press,  Feb.  6,  1867. 

The  chapter  on  Phthisis  is  replete  with  interest; 
and  his  remarks  on  the  diagnosis,  especially  in  the 
early  stages,  are  remarkable  for  their  acumen  and 
great  practical  value.  Dr.  Flint's  style  is  clear  and 
elegant,  and  the  tone  of  freshness  and  originality 


pULLER  {HENRY  "WILLIAM),  M.  D., 

-*■  Phi/sician  to  St.  George's  Hospital,  London. 

ON  DISEASES  OF  THE   LUNGS   AND   AIR-PASSAGES.     Their 

Pathology,  Physical  Diagnosis,  Symptoms,  and  Treatment.  Prom  the  second  and  revised 
English  edition.  In  one  handsome  octavo  volume  of  about  500  pages,  extra  cloth,  $3  50. 
Dr.  Fuller's  work  on  diseases  of  the  chest  was  so  accordingly  we  have  what  might  be  with  perfect  jus- 
favorably  received,  that  to  many  who  did  not  know  j  tice  styled  an  entirely  new  wurk  from  his  pen,  the 
the  extent  of  his  engagements,  it  was  a  matter  of  won-  :  portion  of  the  work  treating  of  the  heart  and  great 
der  that  it  should  be  allowed  to  remain  three  years  I  vessels  being  excluded.  Nevertheless,  this  volume  is 
out  of  print.  Determined,  however,  to  improve  it,  I  of  almost  equal  size  with  the  first. — Loudon  Medical 
Dr.  Fuller  would  not  consent  to  a  mere  reprint,  and  I  Times  and  Gazette,  July  20,  1867. 


TyiLLIAMS  {G.J.B.),  M.D., 

Senior  ConsuUing  Physician  to  the  Hospital  for  Consumption,  Brompton,  and 

TUILLIAAIS  {CHARLES  T.),  M.D., 

Physician  to  the  Hospital  for  Consumption. 

PULMONARY  CONSUjVIPTION;  Its  Nature,  Ytirieties,  and  Treat- 

ment.     With  an  Analysis  of  One  Thousand  cases  to  exemplify  its  duration.     In  one  neat 
octavo  volume  of  about  350  pages,  extra  cloth.      {Just  Issued.)     $2  50. 


He  can  still  speak  from  a  more  enormous  experi- 
ence, and  a  closer  study  of  the  morbid  processes  in- 
volved in  tuberculosis,  than  most  living  men.  He 
owed  it  to  himself,  and  to  tbe  importance  of  the  sub- 
ject, to  embody  his  views  in  a  separate  work,  and 
we  are  glad  that  he  has  accomplished  this  duty. 
After  all,  the  grand  teaching  which  Dr  Williams  has 
for  the  profession  is  to  be  found  in  his  therapeutical 
chapters,  and  in  the  history  of  individual  cases  ex- 
tended, by  dint  of  care,  over  ten,  twenty,  thirty,  and 
even  forty  years. — London  Lancet,  Oct.  21,  1S71. 

His  results  are  more  favorable  than  those  of  any 


previous  author;  but  probably  there  is  no  malady, 
the  treatment  of  which  has  been  so  much  improved 
within  the  last  twenty  years  as  pulmonary  consump- 
tion. To  ourselves,  Dr.  Williams's  chapters  on  Treat- 
ment are  amongst  the  most  valuable  and  attractivein 
the  book,  and  would  alone  render  it  a  standard  work 
of  reference.  In  conclusion,  we  would  record  our 
opinion  that  Dr.  WiJliams's  great  reputation  is  fully 
maintained  by  this  book.  It  is  undoubtedly  one  of 
the  most  valuable  works  in  the  language  upon  any 
special  disease. — Lond.  Med.  Times  and  Gaz.,  Nov. 
4,  1871. 


LA   KOCHE   ON  PNEUMONIA.     1  vol.  Svo.,  extra 

cloth,  of  500  pages.     Price  «8  00, 
BUCKLER  ON    FIBRO-BRONCHITIS  AND  RHEa- 

MATIC  PNEUMONIA.     1  vol.  Svo.     $\  2o. 
FI6KE  FUND  PRIZE  ESSAYS  ON  CONSUMPTION. 

1  vol  8vo,,  extra  cloth.    $1  00. 


SMITH  ON  CONSUMPTION  ;  ITS  EARLY  AND  RE- 
MEDIABLE  STAGES.     1  vol.  Svo,  pp.  254.     $2  25. 

SALTER  ON  ASTHMA.     1  vol.  Svo.     $2  .50. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART  AND 
GREAT  VESSELS.  Third  American  edition.  In 
1  vol.  Svo..  420  pp.,  cloth,    ^y  00. 


18  Henry  C.  Lea's  Publications — {Practice  of  Medicine). 

DOBERTS  (  WILLIAM),  M.  D., 

-*■•'  Lecturer  on  Medicine  in  the  Manchester  School  of  3fedicine,  Ac. 

A  PRACTICAL  TREATISE    ON  URINARY  AND   RENAL   DIS- 

EASES,  including  Urinary  Deposits.    Illustrated  by  numerous  cases  and  engravinffs.    Sec- 
ond American,  from  the  Second  Revised  and  Enhirged  London  Edition.      In    one  large 
and  handsome  octavo  volume  of  616  pages,  with  a  colored  plate  ;  extra  cloth,  $4  50.    (Just 
Ready.) 
The  author  has  subjected  this  work  to  n  very  thorough  revision,  and  has  sought  to  embody  in 
it  the  results  of  the  latest  experience  and  investigations.      Although  every  effort  has  been  made 
to  keep  it  within  the   limits  of  its  former  size,  it  has  l)een  enlarged  by  a  hundred  pnges,  many 
new  wood-cuts  have  been  introduced,  and  also  a  colored  plate  representing  the  ap])earance  of  the 
different  varieties  of  urine,  while  the  price  has  been  retained  at  the  former  very  moderate  rate. 
In  every  respect  it  is  therefore  presented  as  worthy  to  maintain  the  position  which  it  has  acquired 
as  a  leading  authority  on  a  large,  important,  and  perplexing  class  of  affections.     A  few  notices 
of  the  first  edition  are  appended. 

The  plan,  it  will  thus  be  seen,  is  very  complete,  [  diseases  we  have  examined.  It  is  peculiarly  adapted 
anl  the  manner  in  which  it  has  been  carried  out  is  to  the  wants  of  the  majority  of  American  practltioii- 
in  the  hitjhest  degree  satisfactory.  The  characters  j  ers  from  its  clearness  and  simple  announcement  of  the 
of  the  different  de))osits  are  very  well  described,  and  I  facts  in  relation  to  diagnosis  and  frealment  of  urinary 


the  microscopic  appearances  they  present  are  illuS' 
trated  by  numerous  well  executed  engravings.  It 
only  remains  to  us  to  strongly  recommend  to  our 
readers  Dr.  Roberts's  work,  as  coniainingan  admira- 
ble ri'sume  of  the  present  state  of  knowledge  of  uri- 
nary diseases,  and  as  a  safe  and  reliable  guide  to  the 
clinical  observer. — Editi.  JSled.  Jour. 

The  most  complete  and  practical  treatise  upon  renal 


disorders,  and  contains  in  condensed  form  the  investi- 
gations of  Bence  Jones,  Bird,  Bestle,  Hassall.  Prout, 
and  a  host  of  other  well-known  writers  upon  this  sub- 
ject. The  characters  of  urine,  physiological  and  pa- 
thological, as  indicaled  to  the  naked  eye  as  well  as  by 
microscopical  and  chemical  investigations,  are  con- 
cisely represented  both  by  description  and  by  well 
executed  engravings. — Cincinnati  Juurn.  of  Med. 


JDASHAM  {W.R.),  M.D., 

-*-'  Senior  Physician  to  the  Westminster  Hospital,  &c. 

RENAL  DISEASES:  a  Clinical  Guideto  their  Diagnosis  and  Treatment. 

With  illustrations.     In  one  neat  royal  12mo.  volume  of  304  pages.    $2  00.    .{Just  Isstied.) 

-Am. 


The  chapters  on  diagnosis  and  treatment  are  very 
good,  and  the  student  and  young  practitioner  will 
find  them  full  of  valua))le  practical  hints.  The  third 
part,  on  the  urine,  is  excellent,  and  we  cordially 
recommend  its  perusal.  The  author  has  arranged 
his  matter  in  a  somewhat  novel,  and,  we  think,  use- 
ful form.  Here  everything  can  be  easily  found,  and, 
what  is  more  important,  easily  read,  for  all  the  dry 
details  of  larger  books  here  acquire  a  new  interest 
from  the  author's  arrangement.  This  part  of  the 
book  is  full  of  good  work. — Brit,  and  For.  Medico- 
Chirurgical  Review,  July,  1S70. 

The  easy  descriptions  and  compact  modes  of  state- 


ment render  the  book  pleasingand  convenient.- 
Journ.  Med.  Sciences,  July,  1870. 

A  book  that  we  believe  will  be  found  a  valuable 
assistant  to  the  practitionerand  guide  to  the  student. 
— Baltimore  Med.  Journal,  July,  1S70. 

The  treatise  of  Dr.  Basham  dilfers  from  the  rest  in 
its  s|H'cial  adaptation  to  clinical  study,  and  its  con- 
densed and  almost  aphorismal  style,  which  makes  it 
easily  read  and  easily  understood.  Besides,  the 
author  expresses  sume  new  views,  which  are  well 
worthy  of  consideration.  The  volume  is  a  valuable 
addition  to  this  department  of  knowledge. — Pacific 
Mf-d.  and  Surg.  Journal,  July,  1870. 


MORLAND  ON   RETENTION  IN  THE   BLOOD  OF  THE  ELEMENTS  OF  THE   URINARY    SECKETION. 
1  vol.  Svo.,  extra  cloth.    75  cents. 

TONES  [C.  HANDFIELD),  M.  D., 

^  Physician  to  St.  Mary's  Hospital,  &c. 


CLINICAL    OBSERVATIONS 

DISORDERS.     Second  American  Edition, 
extra  cloth,  $.S  25. 

Taken  as  a  whole,  the  work  before  us  furnishes  a  I 
short  but  reliable  account  of  the  pathology  and  treat-  | 
ment  of  a  class  of  very  common  but  certainly  highly 
obscure  disorders.    Theadvanced  student  wi"ll  find  it 
a  rich  mine  of  valuable  facts,  while,the  medical  prac- 
titioner will  derive  from  it  many  a'suggestive  hint  to 
aid  him  in  the  diagnosis  of  "neVvous'cases,"  and  in 
determining  the  true  indications  for  their  ameliora-  ' 
tion  or  cuie.—Amer.  Journ.  Med.  Sci.,  Jan.  1867.         i 


ON    FUNCTIONAL   NERYOUS 

In  one  handsome  octavo  volume  of  348  pages, 

We  must  cordially  recommend  it  to  the  profession 
of  this  country  as  supplying,  in  a  great  measure,  a 
deficiency  which  exists  in  the  medical  literature  of 
the  English  language. — jNVw  I'ork  Med.  Journ.,  April, 
lSt)7. 

The  voluTne  is  a  most  admirable  one — full  of  hints 
and  practical  suggestions.  —  Canada  Med.  Journal, 
April,  1867. 


QiV  BISEASES  OF  THE  SPIXAL  COLUMN  AND  OF  THE  NERVES. 

^^       By  C.  B.  Radcliff,  M.  D.,  and  others.     1  vol.  8vo.,  extra  cloth,  $1  50. 

J^LADE  {D.  D.),  M.D. 

DIPHTHERIA;  its  Nature  and  Treatment,  with  an  account  of  the  His- 
tory of  its  Prevalence  in  various  Countries.  Second  and  revised  edition.  In  one  neat 
royal  12mo.  volume,  extra  cloth.     $1  25. 

BSON{A.),  M.  D.,  M.  R.  lT., 

Physician  to  the  Meath  Hospital. 

LECTURES  ON  THE    STUDY  OF  FEYER.     In  one  vol.  8vo.,  extra 

Cloth,  $2  50. 
'TONS  {ROBERT  D.),  KaToT 
A  TREATISE  ON  FEYER;  or,  Selections  from  a  Course  of  Lectures 

on  Fever.    Being  part  of  a  Course  of  Theory  and  Practice  of  Medicine.   In  one  neat  octavo 
volume,  of  362  pages,  extra  cloth.     $2  26. 


IP 


Henry  C.  Lea's  Publications — (  Venereal  Diseases,  etc.). 


19 


'DUMSTEAD  {FREEMAN  J.),  M.D., 

-*-'         Professor  of  Venereal  Diseases  at  the  Col.  of  Phys.  and  Surg.,  New  York,  &o. 

THE    PATHOLOGY   AND   TREATMENT   OF   VENEREAL  DIS- 
EASES.    Including  the  results  of  recent  investigations  upon  the  subject.     Third  edition, 
revised  and  enlarged,  with  illustrations.     In  one  large  and  handsome  octavo  volume  of 
over  700  pages,  extra  cloth,  $5  00  ;  leather,  $6  00.      {Just  Issued.) 
In  preparing  this  standard  work  again  for  the  press,  the  author  has  subjected  it  to  a  very 
thorough  revision.    Many  portions  have  been  rewritten,  and  much  new  matter  added,  in  order  to 
bring  it  completely  on  a  "level  with  the  most  advanced  condition  of  syphilography,  but  by  careful 
compression  of  the  text  of  previous  editions,  the  work  has  been  increased  by  only  sixtj'-four  pages. 
The  labor  thus  bestowed  upon  it,  it  is  hoped,  will  insure  for  it  a  continuance  of  its  position  as  a 
complete  and  trustworthy  guide  for  the  practitioner. 

It  is  the  most  complete  book  with  which  we  are  ac-  i  much  special  commendation  as  if  its  predecessors  had 
quaiuted  in  the  language.  The  latest  views  of  the  j  not  been  published.  As  a  thoroughly  practical  book 
t'Hst  anfhorities  are  put  forward,  and  the  information  Ion  a  class  of  diseases  which  form  a  large  share  of 
i<  well  arranged — a  great  point  for  the  student,  and  j  nearly  every  physician's  practice,  the  volume  before 
=  till  more  for  the  practitioner.  The  subjects  of  vis-  us  is  by  far  the  best  of  which  we  have  knowledge. — 
c-^ral  syphilis,  syphilitic  affections  of  the  eyes,  and  I  N.  ¥.  Medical  Gazette,  Jan.  28,  1S71. 
the  treatment  ofsyphilis  by  repeatedinoculations,  are  j  n  ig  rare  in  the  history  of  medicine  to  find  anyone 
very  fully  discassei..— London  Lancet,  Jan.  7,  tS71.  ^goij  ^^ich  contains  all  that  a  practitioner  needs  to 
Dr.  Bumstead's  work  is  already  so  universally  know;  wUile  the  possessor  of  "Bumstead  on  Vene- 
kaown  as  the  best  treatise  in  the  English  language  on  [  real"  has  no  occasicm  to  look  outside  of  its  covers  for 
venereal  diseases,  that  it  may  seem  almost  superflu-  |  anything  practical  counected  with  the  diagnosis,  his- 
'US  to  say  more  of  it  than  that  a  new  edition  has  been  i  toiy,  or  treatment  of  these  affections. — N.  Y.  Medical 
■.-sued.  But  the  author's  industry  has  rendered  this  j  Journal,  March,  1871. 
new  edition  virtually  a  new  work,  and  so  merits  as  ' 


pULLERIER  [A.),  and 

^  Surgeon  to  the  Edpital  du  Midi. 


:  College  of 


T? UMSTEA D  [FREE MA N  J.), 

■^-'       Professor  of  Venereal  Diseases  in  the  d 
PhijsiciOMS  and  Surgeons,  N.  Y. 

AN  ATLAS  OF  VENEREAL  DISEASES.     Translnted  and  Edited  by 

Freeman  J.  Bumstead.     In  one  large  imperial  4to.  volume  of  328  pages,  double-columns, 
with  26  plates,  containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of 
life;  strongly  bound  in  extra  cloth,  $17  00 ;  also,  in  five  parts,  stout  wrappers  for  mailing,  at 
$.3  per  part.      (Lately  Published.) 
Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  very  low  price  of  Three  Dol- 
lars a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this  department  of  prac- 
tice.    Gentlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without  delay. 
A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 
We  wish  for  once  that  our  province  was  not  restrict-  ;  which  for  its  kind  is  moi'e  necessary  tor  them  to  have. 


ed  to  methods  of  treatment,  that  we  might  say  some- 
thing of  the  exquisite  colored  plates  in  this  volume. 
— London  Practitioner,  May,  1869. 

As  a  whole,  it  teaches  all  that  can  be  taught  by 
means  of  plates  and  print. — London  Lancet,  March 
13,  1869. 

Superior  to  anything  of  the  kind  ever  before  issued 
on  this  continent. — Canada  Metl.  Journal,  March,  '69. 

The  practitioner  who  desires  to  understand  this 

branch  of  medicine  thoroughly  should  obtain  this,         

the  most  complete  and  best  work  ever  published.—  [  good  account  of  the  diseases  of  which  he  treats,  but 
Di^minion  Med.  Journal,  May,  1869.  ;  ^o  one  has  furnished  us  with  such  a  complete  series 

This  is  a  work  of  master  hands  on  both  sides.  M.  '  of  illustrations  of  the  venereal  diseases.  There  is, 
Cullerier  is  scarcely  second  to,  we  think  we  may  truly  j  however,  an  additional  interest  and  value  possessed 
say  is  a  peer  of  the  illustrious  and  venerable  Ricord,  by  the  volume  before  us  ;  for  it  is  an  American  repritit 
while  in  this  country  we  do  not  hesitate  to  say  that  j  and  translation  of  .M.  Cullerier's  work,  with  inci- 
Dr.  Bumstead,  as  an  authority,  is  without  a  rival.  ;  dental  remarks  by  one  of  the  most  eminent  Ameriran 
Assuring  our  readers  that  these  illustrations  tell  the  i  syphilographers,  Mr.  Bumstead. — Brit,  and  For. 
whole  history  of  venereal  disease,  from  its  inception  Medico-Chir.  Review,  July,  1869. 
to  its  end,  we  do  not  know  a  single  medical  work,  i 


— Calif )rnia  Med.  Gazette,  March,  1869. 

The  most  splendidly  illustrated  work  in  the  lan- 
guage, and  in  our  opinion  far  more  useful  than  the 
French  original — Am.  Jour n.  Med.  Scienceji,  Jan. '69. 

The  fifth  and  concluding  number  of  this  magnificent 
work  has  reached  us,  and  we  have  no  hesitation  in 
saying  that  its  illustrations  surpass  those  of  previous 
numbers.— Bo«fow.  Med.  and  Surg.  Journal,  Jan.  14, 
1869. 

Other  writers  besides  M.  CuUerier  have  given  ns  a 


// 


ILL  {BERKELEY), 

Surgeon  to  the  Lock  Hospital,  London. 


In 


ON  SYPHILIS  AND  LOCAL  CONTAGIOUS  DISORDERS. 

one  handsome  octavo  volume  ;  extra  cloth,  $3  25.     {Lately  Published.) 

to  whom  we  would  most  earnestly  recommend  its 
study  ;  while  it  is  no  less  useful  to  the  practitioner.— 
St.  Louis  Med.  and  Surg.  Journal,  May,  1869. 


Bringing,  as  it  does,  the  entire  literature  of  the  dis- 
ease down  to  the  present  day,  and  giving  with  great 
ibility  the  results  of  modern  research,  it  is  in  every 
respect  a  most  desirable  work,  and  one  which  should 
find  a  place  in  the  library  of  every  surgeon. — Cali- 
fornia Med.  Gazette,  June,  1869. 

Considering  the  scope  of  the  book  and  the  careful 
attention  to  the  manifold  aspects  and  details  of  its 
subject,  it  is  wonderfully  concise.  All  these  qualities 
reader  it  an  especially  valuable  book  to  the  beginner. 


The  most  convenient  and  ready  book  of  reference 
we  have  met  with.— iV.  Y.  Med.  Record,  May  1, 1869. 

Most  admirably  arranged  for  both  student  and  prac- 
titioner, no  other  work  on  the  subject  equals  it ;  it  is 
more  simple,  more  easily  studied. — Buffalo  Med.  and 
Surg.  Journal,  March,  1869. 


2JEISSL  (R),  M.D. 

A  COMPLETE  TREATISE  ON  VENEREAL  DISEASES.  Trans- 
lated from  the  Second  Enlarged  Gertnnn  Edition,  by  FaEDEnic  R.  Sturgis,  M.D.  In  one 
octavo  volume,  with  illustrations.     {Preparijig.) 


20 


Henry  C.  Lea's  Publications — (Diseases  of  the  Skin). 


l^riLSON  ( ERASE  US ) ,  F.  R.  S. 

ON  DISEASES  OF  THE  SKIK  With  Illustrations  on  wood.  Sev- 
enth American,  from  the  sixth  and  enlarged  English  edition.  In  one  large  octavo  volume 
of  over  800  pages,  $5. 

A  SERIES   OF   PLATES   ILLUSTRATING  "WILSON   ON  DIS- 

EASES  OP  THE  SKINj"  consisting  of  twenty  beautifully  executed  plates,  of  which  thir- 
teen are  exquisitely  colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  Skin, 
and  embracing  accurate  representations  of  about  one  hundred  varieties  of  disease,  most  of 
them  the  size  of  nature.     Price,  in  extra  cloth,  $5  60. 
Also,  the  Text  and  Plates,  bound  in  one  handsome  volume.     Extra  cloth,  $10. 

No  one  treating  skin  dis-eases  shonld  be  without 
a   ciipy  of  this  standard   work. —  Canada  Lancet, 
August,  1S63. 
We  can  safely  recommead  it  to  the  profession  as 


Such  a  work  as  the  one  before  us  is  a  most  capital 
and  acceptable  help.  Mr,  Wilson  has  long  been  held 
as  high  authority  in  this  department  of  medicine,  and 
his  book  on  diseases  of  the  skin  has  long  been  re- 
garded as  one  or  the  best  text-books  extant  on  the 
subject.  The  present  edition  is  carefully  prepared, 
and  brought  up  in  its  revision  to  the  present  time.  In 
th-8  edition  we  have  also  included  the  beautiful  series 
of  plates  illustrative  of  the  text,  and  in  the  last  edi- 
tion published  separately.  There  are  twenty  of  these 
platen,  nearly  all  of  them  colored  to  nature,  and  ex- 
hibiting with  great  fidelity  the  various  groups  of 
diseases. — Ginainnati  Lancet. 


the  best  work  on  the  subject    now  in   existence  in 
the  English  language. — Mtdical  Times  and  Gazette. 

Mr.  Wilson's  volume  is  an  excellent  digest  of  the 
actual  amount  of  knowledge  of  cutaneous  diseases; 
it  includes  almost  every  fact  or  opinion  of  importance 
connected  with  the  anatomy  and  pathology  of  th« 
skin. — British  and  Foreign  Medical  Review. 


B 


Y  THE  SAME  AUTHOR.  

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE  and  Dis- 

EASES  OF  THE  SKIN.    In  One  very  handsome  royal  12mo.  volume.    $3  50.    {Lately  Issued.) 


JYELIGAN  {J.  310 ORE),  M.D.,  M.R.I.A. 

A    PRACTICAL    TREATISE    ON    DISEASES    OF    THE    SKIN. 

Fifth  American,  from  the  second  and  enlarged  Dublin  edition  by  T.  W.  Belcher,  M.D. 
In  one  neat  royal  12mo.  volume  of  462  pages,  extra  cloth.     $2  25. 


Fu'lly  equal  to  all  the  requirements  of  students  and  i 
young  practitioners. — Dahlia  Med.  Press. 

Of  the  remainder  of  the  work  we  have  nothing  be-  I 
yond  unqualified  commendation  to  offer.     It  is  so  far 
the  most  complete  one  of  its  size  that  has  appeared,  [ 
and  for  the  student  there  can  be  none  which  can  com-  1 
pare  with  it  in  practical  value.     All  the  late  disco- 
veries in  Dermatology  have  been  duly  noticed,  and 

)r  TEE  SAME  AUTHOR.  


heir  value  justly  estimated;  in  a  word,  the  work  is 
fully  up  to  the  times,  and  is  thoroughly  stocked  with 
most  valuable  information. — iVeio  York  Med.  Record, 
Jan.  1.0,  18»)7. 

The  most  convenienf  manual  of  diseases  of  the 
skin  that  can  be  i>rocuref:  by  the  student. — Chicago 
Med.  Journal,  Dec.  18(J6. 


B^ 


ATLAS   OF   CUTANEOUS   DISEASES. 


In   one  heautiful   quarto 

volume,  with  exquisitely  colored  plates,  Ac,  presenting  about  one  hundred  varieties  of 

disease.     Extra  cloth,  $5  50. 

inclined  to  consider  it  a  very  superior  work,  com- 
bining accurate  verbal  description  with  soAnd  view* 
of  the  pathology  and  treatment  of  eruptive  diseases. 
—  Glnsgftw  Med.  Jnurnal. 

A  compend  which  will  very  ranch  aid  the  practi- 
tioner in  this  difficult  branch  of  diagnosis  Taken 
with  the  bpautiful  plates  of  the  Atlas,  which  are  re- 
markable for  their  accuracy  and  beauty  of  coloring, 
it  constitutes  a  very  valniib'le  addition  to  the  library 
of  a  practical  man. — Buffalo  Med.  Journal. 


The  diagnosis  of  eruptive  disease,  however,  under 
all  circumstances,  is  very  difiicult.  Nevertheless, 
Dr.  Neligan  has  certainly,  "as  far  as  possible,"  given 
a  faithful  and  accurate  representation  of  this  class  of 
diseases,  and  there  can  be  no  doubt  that  these  plates 
will  be  of  great  use  to  the  student  and  practitioner  in 
drawing  a  diagnosis  as  to  the  class,  order,  and  species 
to  which  the  particular  case  may  belong  While 
looking  over  the  "Atlas"  we  have  been  induced  to 
examine  also  the  "Practical  Treatise."  and  we  are 


TJILLIER  [THOMAS),  M.D., 

■'--^  Phi/.ticinn  to  the  Skin  Department  of  University  College  Hosjntal,  &e. 

HAND-BOOK  OF  SKIN  DISEASES,  for  Students  and  Practitioners. 

Second  American  Edition.     In  one  royal  12mo.  volume  of  358  pp.     With  Illustrations. 
Extra  cloth,  $2  25. 

We  can  conscientiously  recommend  it  to  the  sfu-  1  It  is  a  concise,  plain,  practical  treatise  on  the  van- 
dent ;  the  style  is  clear  and  pleasant  to  read,  the  |  ous  diseases  of  the  skin  ;  just  such  a  work,  indeed, 
mavter  IS  good,  and  the  descriptions  of  disease,  with  \  as  was  much  needed,  both  by  medical  students  and 
ttie  modes  ot  treatment  recommended,  are  frequently  i  practitioners.  —  CAicaoo  Medical  Examir^er,  May, 
Illustrated  with  well-recorded  CAi&s,.— London  Med  1865 
Tiraes  and  Gazette,  April  1,  1865. 


A  NDERSON  (McCALL),  M.D., 

-^J-  Physician  to  the  Dispensary  for  Skin  Diseases,  Glasgow,  &c. 

ON  THE  TREATMENT  OF  DISEASES  OF  THE  SKIN.     With  an 

Analysis  of  Eleven  Thousand  Consecutive  Cases.     In  one  vol.  8vo.      (Publishing  in  the 

Medical  News  and  Library  for  1873.} 
The  very  practical  ch.nracter  of  this  work  and  the  extensive  experience  of  the  author,  cannot 
fail  to  render  it  acceptable  to  the  subscribers  of  the  "Americas  Jouun'al  of  the  Mgdic\i. 
Sciences."     When  completed  in  the  "News  and  Librarv,"  it,  will  be  issued  separately  in  a 
neat  octavo  volume. 


Henry  C.  Lea's  Publications — (Diseases  of  Children).  21 

UMITH  {J.  LE  WIS\  M.  D., 

^^  Pro/esxor  of  Morbid  Anatomy  in  the  Bellf.vue,  Hospital  Med.  College,  N.  ¥. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

CHILDREN.     Second  Editioa,  revised  and  greatly  enlarged.      In  one  handsome  octavo 
volume  of  742  pages,  extra  cloth,  $5;  leather,  $6.      (Now  Ready.) 
From  the  Pueface  to  the  Second  Edition. 

In  presenting  to  the  profession  the  second  edition  of  his  work,  the  author  gratefully  acknow- 
ledges the  favorable  reception  accorded  to  the  first.  He  has  endeavored  to  merit  a  continunnce 
of  this  approbation  by  rendering  the  volume  much  more  complete  than  before.  Nearly  twenty 
additional  diseases  have  been  treated  of,  among  wliich  may  be  named  Diseases  Incidental  to 
Birth,  Rachitis,  Tuberculosis,  Scrofula,  Intermittent,  Remittent,  and  Typhoid  Fevers,  Chorea, 
and  the  various  forms  of  Paralysis.  Many  new  formuliB,  which  experience  has  shown  to  be 
useful,  have  been  introduced,  portions  of  the  text  of  a  less  practical  nature  have  been  con- 
densed, and  other  portions,  especially  those  relating  to  pathological  histology,  have  been 
rewritten  to  correspond  with  recent  discoveries.  livery  effort  has  been  made,  however,  to  avoid 
an  undue  enlargement  of  the  volume,  but,  notwithstanding  this,  and  an  increase  in  the  size  of 
the  page,  the  number  of  pages  has  been  enlarged  by  more  than  one  hundred. 

227  West  49Tn  Street,  New  York,  April,  1872. 

The  work  will  be  found  to  contain  nearly  one-third  more  matter  than  the  previous  edition,  and 
it  is  confidently  presented  as  in  every  respect  worthy  to  be  received  as  the  standard  American 
text-book  on  the  subject. 


Eminently  practical  as  well  as  judicious  in  its 
teachings. — Cincinnati  Lancet  and  Ohs.,  July,  1S72. 

A  standard  work  ihat  leaves  little  to  be  desired. — 
Indiana  Journal  of  Medicine,  July,  1S72. 

We  know  of  no  book  on  this  subject  that  we  can 
more  cordially  recommend  to  the  medical  student 
and  thepractitioner. — Cincinnati  Clinic,  June  29,  '72. 


We  regard  it  as  superior  to  any  other  single  work 
on  the  diseases  of  infancy  and  childhood. — Detroit 
Rev.  of  Med.  and  Pharmacy,  Aug.  1872. 

We  confess  to  increased  enthusiasm  in  recommend- 
ing this  second  edition. — St.  Louis  Med.  and  Surg. 
Journal,  Aug.  1S72. 


rtONDIE  {D.  FRANCIS),  M.D. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN. 

Sixth  edition,  revised  and  augmented.     In  one  large  octavo  volume  of  nearly  800  closely- 
printed  pages,  extra  cloth,  $5  25;  leather,  $6  25s       {Lately  Issued.) 
The  present  edition,  which  is  the  sixth,  is  fully  np  I  teachers.     As  a  whole,  however,  the  work  is  the  best 
to  the  times  in  tire  discussion  of  all  those  points  in  the  |  American  one  that  we  have,  and  in  its  special  ad  apt  a- 
pathology  and  treatment  of  infantile  diseases  which  I  tion   to  American  practitioners  it  certainly  has   no 
have  been  brought  forward  by  the  German  and  French  |  equal.  —  New  York  Med.  Record,  March  2,  1S6S. 


^EST  [CHARLES),  31. D., 

'  '  Physician  to  the  Hospital  for  Sick  Children,  Sre. 

LECTURES  ON   THE   DISEASES   OF   INFANCY  AND  CHILD- 

HOOD.  Fourth  American  from  the  fifth  revised  and  enlarged  English  edition.  In  one 
large  and  handsome  octavo  volume  of  656  closely-printed  pages.  Extra  cloth,  $4  50 ; 
leather,  $6  50. 

Of  all  the  English  writers  on  the  diseases  of  chil- 1  living  authorities  in  the  difficult  department  of  medl- 
dren,  there  is  no  one  so  entirely  satisfactory  to  us  as  (  cal  science  in   which  he  is   most  widely  known.— 
Dr.  West.    For  years  we  have  held  his  opinion  as  I  Boston  Med.  and  Surff.  -Journal,  April  26,  1866. 
Jadicial,  and  have  regarded  him  as  one  of  the  highest  | 


T}Y  THE  SAME  AUTHOR.    {Lately Lssued.) 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 

HOOD;  being  the  Lumleian  Lectures  delivered  at  the  Royal  College  of  Physicians  of  Lon- 
don, in  March,  1871.     In  one  volume,  small  12mo.,  extra  cloth,  $1  00. 

milTH [EUSTACE),  M.  D., 

Physician  to  the  Northioest  London  Free  Di.9pe71.9nry  for  Sick  Children. 

A  PRACTICAL  TREATISE  ON   THE  WASTING   DISEASES  OF 

INFANCY  AND  CHILDHOOD.     Second  American,  from  the  second  revised  and  enlarged 
English  edition.     In  one  handsome  octavo  volume,  extra  cloth,  $2  50.      {Lately  Issued.) 


This  is  in  every  way  an  admirable  book.  The 
modest  title  which  the  author  has  chosen  for  it  scarce- 
ly conveys  an  adequate  idea  of  the  many  subjects 
upon  which  it  treats.  Wasting  is  so  constant  an  at- 
tendant upon  the  maladies  of  childhood,  that  a  trea- 
tise upon  the  wasting  diseases  of  children  must  neces 
sarily  embrace  the  consideration  of  many  aU'eclions 
of  which  it  is  a  symptom  ;  and  this  is  excellently  well 
done  by  Dr.  Smith.     The  book  might  fairly  be  de- 


scribed as  a  practical  handbook  of  the  common  dis- 
eases of  children,  so  numerous  are  the  affections  con- 
sidered either  collaterally  or  directly.  We  are 
acquainted  with  no  safer  guide  to  the  treatment  of 
children's  diseases,  and  few  works  give  the  insiglit 
into  the  physiological  and  other  peculiarities  of  chil- 
dren that  Dr.  Smith's  book  does. — Brit.  Med.  Joiirn., 
April  S,  IftTl. 


QUERSANT  [P.),  M.  D., 

Honorary  Surgeon  to  the  Hospital  for  Sick  Children,  Paris. 

SURGICAL  DISEASES  OF  INFANTS  AND  CHILDREN.     Trans- 

lated  by  R.  J.  Dunglison,  M.  D.     In  one  neat  octavo  volume,  extra  cloth,  $2  50.     {Now 
Ready  ) 

DEWEES  ON  THE  PHYSICAL  AND  MEDICAL  TEEATMENT  OF  CHILDREN.     Eleventh  edition.    1  voL 
8to.  of  o4S  pages.    $2  80. 


22  Henry  C.  Lea's  Publications — (Diseases  of  Women). 

A  VELTNG  [JAMES  H.),  and    T^ILTSHIRE  [ALFRED],  31. D., 

-^^  Pliysicirin  to  the  Hospital  for  Women  and  •'  Asuistcnit  Phi/xi-ian-Accouclieur  toSt. 

Chiblren.  Mary's  Hoapitnl. 

THE    OBSTETRICAL    JOURNAL    of   Great    Britain   and  Irelaiul ; 

Including  Mipwifeuy,  .ind  the  Diseases  of  Women  and  Infants.     With  an  American 
Supplement,  edited  by  William  F.  Jenks,  M.D.      A  monthly  of  about  SO  octavo  pages, 
very  handsomely  printed.     Subscription,  Five  Dollars  per  annum.      Single  Numbers,  50 
cents  each. 
Commencing  with  April,  187.3,  the  Obstetrical  Journal  will  consist  of  Original  Pnpers  by  Brit- 
ish and  Foreign  Contributors  ;   Transactions  of  the  Obstetrical  Societies  in  England  and  abroad  ; 
Reports  of  Ilospitnl  Practice;   Reviews  and  Bibliographical  Notices;   Articles  and  Notes,  Edito- 
rial,  Historical,  Forensic,  and  Miscellaneous;   Selections  from  Journals;   Correspondence,   Ac. 
Collectino-  together  the  vast  amount  of  material  daily  accumulating  in  this  important  and  ra- 
pidly improving  department  of  medical  science,  the  value  of  the  information  which  it  will  pre- 
sent to  the  subscriber  may  be  estimated  from  the  chara.cter  of  the  gentlemen  who  have  already 
promised  their  support,  including  such  names  as  those  of  Drs.  Atthill,  Robert  Barnes,  Henry 
Bbnnet,   Thomas  Chambers,  Fleetwood  Churchill,  Matthews  Duncan,  Graily  Hewitt, 
Braxton  Hicks,  Alfrf.d  Meadows,  W.  Leishman,  Alex.  Simpson  Tyler  Smith,  Edward  J. 
Tilt,  Spencer  Wells,  &c.  &c.  ;  in  short, the  representative  men  of  British  Obstetrics  and  Gynae- 
cology. 

In  order  to  render  the  Obstetrical  Journal  fully  adequate  to  the  wants  of  the  American 
profession,  each  number  will  contain  a  Supplement  devoted  to  the  advance*  made  in  Obstetrics 
and  Gyneeoology  on  this  side  of  the  Atlantic.  This  portion  of  the  Journal  will  be  under  the 
editorial  charge  of  Dr.  William  F.  Jenks,  to  whom  editorial  communications,  exchanges,  books 
for  review,  &c.,  may  be  addressed,  to  the  care  of  the  publisher. 

*-3*"  Gentlemen  desiring  complete  sets  will  do  well  to  forward  their  orders  without  delay. 


fTHOMAS  [T.  GAILLARD),M.D., 

-*•  Pro/es.ior  of  Obstetrics,  &c  ,  in  the  College  of  Physicians  and  Surgeons,  N.  Y.,  &c. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.    Third 

edition,  enlarged  and  thoroughly  revised.     In  one  large  and  handsome  octavo  volume  of 
784  pages,  with  246  illustrations.    .Cloth,  $5  00;   leather,  $6  00.     (Just  Issued.) 

The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  another  edition  of 
this  work  to  render  it  worthy  a  continuance  of  the  very  remarkable  favor  with  which  it  has  been 
received.  Every  portion  has  been  subjected  to  a  conscientious  revision,  several  new  chapters 
have  been  added,  and  no  labor  spared  to  make  it  a  complete  treatise  on  the  most  advanced  con- 
dition of  its  important  subject.  The  present  edition  therefore  contains  about  one-third  more 
matter  than  the  previous  one,  notwithstanding  which  the  price  has  been  maintained  at  the  former 
very  moderate  rate,  rendering  this  one  of  the  cheapest  volumes  accessible  to  the  profession. 

A.s  compared  with  the  first  edition,  five  new  chap-  •  We  are  free  to  say  that  we  regard  Dr.  Thomas  the 
ters  on  dysmenori-liCEa,  peri-uteriue  fluid  tumors,  best  American  auth.irity  on  di.-^eases  of  women.  Seve- 
composite  tumors  of  the  ovary,  solid  tumors  of  the  |  ral  others  have  written,  and  written  well,  bnt  none 
ovary,  and  chlorosis,  liave  been  added.  Twenty-  [  have  no  clearly  and  carefully  arranged  their  text  and 
seven  additional  woodcuts  have  been  introduced,  !  instruction  as  Dr.  Thomas. — Vincinnait  Lancet  and 
mauy  subjects  have  been  subdivided,  and  all  have     Observer,  May,  1872. 

^^^f^t  '?^P^''^"'  interstitial  increase.  In  fact,  the  We  deem  it  scarcely  necessery  to  recommend  this 
olLi  f  i"  P''^^''^''"-^  rewritten,  and  great  y  in-  :  ^^,.^  to  physicians  as  it  is  now  widely  known,  and 
of  n  .  hnnVw,  1  I^'"^fl>'- ^^  may  say  that  we  kuow  ,  ^lost  of  them  already  possess  it,  or  will  certainly  do 
Ln?  fho  l^i  ?  so  completely  and  concisely  repre-  ,  g„  ^o  students  we  unhesitatingly  recommend  it  as 
of  we  1  Hi^P  tp7  T  r  fr'?""';'^^  '  °°°®  '°J"u  i  ^^"^  best text-book  on  diseases  of  females  extant.-^'<. 
hesLlv^fn  i  ,1  ''"'''^'!  teaching;  none  which  !  i„„^^  yf^^  Reporter,  June.  1S69. 
bespeaks  an  author  more  apt  in  research  and  abnn-  z'  >  ■ 

dant  in  resources. — N.  Y.  Med.  Record,  May  1, 1872.  1      Of  all  the  army  of  books  that  have  appeared  of  late 

Wo  shniii^  n/>t  >,(.  ^„;„„ J, .„.„.!  r'     •         fears.  On  the  dissases  of  the  uterus  aud  its  appendages, 

did  we  no    tell  t lol  wl?'.^..        ^      '  .  T    fw?°     ^^  kt^ow  of  none  that  is  so  clear,  comprehensive,  and 

boo^  how  m  1  cb    f  ifv^  MP  ,  unacquainted  with  the  ;  practical  as  this  of  Dr.  Thomas',  ir  one  that  we  should 

uooK,  now  TTiucn  it  is  valued  by  evnaecoloaristR   and  '  „  i.    .•     n  i   ..     .t 

how  it  is  in  manv  respects  one  of  Uie  best  text-books  ;  T'^  emphatical  y  recommend  to  the  young  practi- 

on  the  subject  we  possess  in  our  language.     We  have      c'r""'  ^'  ^'  guide.-Cai//ornia  Med.  Gazette.  June, 

no  hesitation  in  recommending  Dr.  Thomas's  work  as  i 

one  of  the  most  complete  of  its  kind  ever  published.  ;      "f  "o*  "^^  heisi  work  extant  on  the  subject  of  which 

It  should  be  in  the  possession  of  every  practitioner    "  treats,  it  is  certainly  second  to  none  other.     So 

for  reference  and  for  s\.\xi.\y.— London  Lancet,  April     short   a   time  has  elapsed  since   the   medical   press 

27,1872.  '  I  teemed  with  commendatory  notices  of  the  first  edition. 

Our  author  is  not  one  of  those  whose  views  "never  '  'J?^i IV "^71*^-  '''  •^iipe'-fl"""';  to  give  an  extended  re- 
change."  On  the  contrary,  ihey  have  been  modified  1  LTk '^T^Vr  i™^  es^bhshed  as /7.«  American 
in  many  particulars  to  accord  with  the  progress  made  '  7''  Vr™  "  ''^  Gyf^eol^g/--^-  ^-  ^<^d-  Gazette,  July 
in  this  department  ofmedical  science:  hence  it  has  the 

fieshaess  of  an  entirely  new  work.  No  general  prac-  j  T^'^s  is  a  new  and  revised  edition  of  a  work  which 
titioner  can  afford  to  be  without  it. — St.  Louis  Med.  \  ^^  recently  noticed  at  some  length,  and  earnestly 
and  Surg  Journal,  May,  1872.  ,  commended  to  the  favorable  attention  of  our  readers. 

Its  able  author  need  not  fear  comparison  between  1  "^^^  fact  that,  in  the  short  space  of  one  year,  this 
it  and  any  similar  work  in  the  English  lanuuaee  •  second  edition  makes  its  appearance,  shoivs  that  the 
nay  more,  as  a  text  book  for  studenrs  and  as  a  guide  f°f",al  Judgment  of  the  profession  has  largely  con- 
f  .r  practitioners,  we  believe  it  is  unequal  led  In  the  ,  ^"^e^^ ''l''  ''P?!'!?  ^^  S^^®  *'  that  iimt,.- Cincinnati 
libraries  of  reading   phy,.icians   we  meet   with    it     ^"''^^'  ^"«-  ^'"'^• 

oftener  than  any  other  treatise  on  disea.ses  of  women.  I  It  is  so  short  a  time  since  we  gave  a  full  review  of 
wecouclndeourhriefreviewbyrepeatingthehearty  I  the  first  edition  of  this  book,  that  we  deem  it  only 
mo^!!i7  ■'i  ?.'\,°'^  V  ^^  volume  gi^en  when  we  com-  ,  necessary  now  to  call  attention  to  the  second  appear- 
menceu:  it  either  student  or  practitioner  can  get  but  ance  of  the  work.  'Its  success  has  been  remarkable, 
one  book  on  diseases  of  women  that  book  should  be  !  and  we  can  only  congratulate  the  author  on  the 
1879°'°'^'*'  ~^"'*'"-  ■^''"»'-  ^^^'i-  Sciences,  April,  1  brilliant  reception  his  book  has  received.— A'.  Z.  Jf«d. 
^^'^-  I  Journal,  April,  1869. 


Henry  C.  Lea's  Publications — (Diseases  of  Women). 


23 


jrODGE  (HUGfT  L.),  M.D., 

-*-*■  Eme.ritvx  Prnfessor  of  Ohfitdrics,  &c.,  in  thp.  Univer-tity  nf  Pennsylvania. 

ON  DISEASES  PECFLIAR  TO  WOMEX;  includin.^  Displacements 

of  the  uterus.  With  original  illustrations. .  Second  edition,  revised  and,  enlarged.  In 
one  beautifully  printed  octavo  volume  of  531  pages,  extra  cloth.  $4  50.  (jjuteiy  Issvfd.) 
In  the  preparation  of  this  edition  the  author  has  spared  no  pains  to  improve  it  with  the  results 
of  his  observation  and  study  during  the  interval  which  has  elapsed  since  the  first  appearance  of 
the  work.  Considerable  additions  have  thus  been  m.nde  to  it,  which  have  been  partially  accom- 
modated by  an  enlargement  in  the  size  of  the  page,  t©  avoid  increasing  unduly  the  bulk  of  the 
volume. 


From  Prof.  W.  H.  Btford,  nf  the  Rush  Medical 
College,  Ohicngo. 

The  book  bears  the  impress  of  a  master  hand,  and 
must,  as  its  predecessor,  prove  acceptable  to  the  pro- 
fession. In  diseases  of  women  Dr.  Hodge  has  estab- 
lished a  school  of  treatment  that  has  become  world- 
wide in  fame. 

Professor  Hodge's  work  Is  truly  an  original  one 
from  beginning  to  end.  consequently  no  one  can  pe- 
ruse its  pages  without  learning  something  new.  The 
book,  which  is  by  no  means  a  large  one,  is  divided  into 
two  grand  sections,  so  to  speak  :  first,  that  treating  of 
the  nervons  sympathies  of  the  uterus,  and,  secondly, 
that  which  speaks  of  the  mechanical  treatment  of  dis- 
placements of  that  organ.  He  is  disposed,  as  a  non- 
believer  in   the  frequency  of  inflammations  of  the 


nterns,  to  take  strong  ground  against  many  of  the 
highest  authorities  in  this  branch  of  medicine,  and 
the  arguments  which  he  offers  in  support  of  his  posi- 
tion are,  to  say  the  least,  well  put.  Numerous  wood- 
cuts adorn  this  portion  of  the  work,  and  add  incalcu- 
lably to  the  proper  appreciation  of  the  variously 
shaped  instruments  referred  to  by  our  aathor.  As  a 
contribution  to  the  study  of  women's  diseases,  it  is  of 
great  value,  and  is  abundantly  able  to  stand  on  its 
own  merits. — N.  Y.  Medical  Record,  Sept.  15,  1868. 

In  this  point  of  view,  the  treatise  of  Professor 
Hodge  will  be  indispensable  to  every  student  in  its 
department.  The  large,  fair  type  and  general  perfec- 
tion of  workmanship  will  render  it  doubly  welcome. 
— Pacific  Med.  and  Surg.  Journal,  Oct.  1868. 


'W'EST  [CHARLES],  M.D. 

LECTURES  OX  THE  DISEASES  OF  WOMEX.    Third  American, 

from  the  Third  London  edition.     In  one  neat  octavo  volume  of  about  550  pages,  extra 

cloth,    $3  75  ;  leather,  $4  75. 
The  reputation  which  this  volume  has  acquired  ns  a  standard  book  of  reference  in  its  depart- 
ment, renders  it  only  necessary  to  say  that  the  present  edition  has  received  a  cnreful  revision  at 
the  hands  of  the  author,  resulting  in  a  considerable  increase  of  size.     A  few  notices  of  previous 
editions  are  subjoined. 


The  manner  of  the  author  is  excellent,  hi.s  descrip- 
tions graphic  and  perspicuous,  and  his  treatment  up 
to  the  level  of  the  time— clear,  precise,  definite,  and 
marked  by  strong  common  sense.  —  Chicago  Med. 
Journal,  Dec.  1861. 

We  cannot  too  highly  recommend  this,  the  second 
edition  of  Dr.  West's  excellent  lectures  on  the  dis- 
eases of  females.  We  know  of  no  other  book  on  this 
subject  from  which  we  have  derived  as  much  pleasure 
and  instruction.  Every  page  gives  evidence  of  the 
honest,  earnest,  and  diligent  searcher  after  truth.  He 
Is  not  the  mere  compiler  of  other  men's  ideas,  but  his 
lectures  are  the  result  often  years'  patient  investiga- 
tion in  one  of  the  widest  fields  for  women's  disease.s — 
8t.  Bartholomew's  Hospital.  As  a  teacher.  Dr.  West 
is  simple  and  earnest  in  his  language,  clear  and  com- 
prehensive in  bis  perceptions,  and  logical  in  his  de- 
ductions.— Cincinnati  Lancet,  Jan.  1862. 

We  return  the  author  our  grateful  thanks  for  the 
vast  amount  of  instruction  he  has  afforded  us.  His 
valuable  treatise  needs  no  eulogy  on  our  part.  His 
graphic  diction  and  truthful  pictures  of  disease  all 
speak  for  themselves. — Medico-Chirurg.  Review, 

Most  justly  esteemed  a  standard  work It 

bears  evidence  of  having  been  carefully  revised,  and 
Is  well  worthy  of  the  fame  it  has  already  obtained. 
—Dub.  Med.  Quar.  Jour. 


As  a  writer.  Dr.  West  stands,  in  our  opinion,  se- 
cond only  to  Watson,  the  "Macaulay  of  Medicine;" 
he  possesses  that  happy  faculty  of  clothing  instruc- 
tion in  easy  garments;  combining  pleasure  with 
profit,  he  leads  his  pupils,  in  spite  of  the  ancient  pro- 
verb, along  a  royal  road  to  learning.  His  work  is  one 
which  will  not  satisfy  the  extreme  on  either  side,  but 
it  is  one  that  will  please  the  great  majority  who  are 
seeking  truth,  and  one  that  will  convince  the  student 
that  he  has  committed  himself  to  a  caudid,  safe,  and 
valuable  guide. — N.  A.  Med.-Chirurg  Review. 

We  must  now  conclude  this  hastily  written  sketch 
with  the  confident  assurance  to  our  readers  that  the 
work  will  well  repay  perusal.  The  conscientious, 
painstaking,  practical  physician  is  apparent  on  every 
page. — N.  ¥.  Journal  of  Medicine. 

We  have  to  say  of  it,  briefly  and  decidedly,  that  it 
is  the  best  work  on  the  subject  in  any  language,  and 
that  it  stamps  Dr.  West  as  the  facile  princeps  of 
British  obstetric  authors. — Edinburgh  Med.  Journal. 

We  gladly  recommend  his  lectures  as  in  the  highest 
degree  instructive  to  all  who  are  interested  in  ob- 
stetric practice. — London.  Lancet. 

We  know  of  no  treatise  of  the  kind  so  complete, 
and  yet  so  compact. — Chicago  Med.  Journal. 


B 


ARNES  [ROBERT],  M.  D.,  F.R.G.P., 

Obstetric  Physician  to  St.  Thoma.s's  Hospital,  &e. 

A  CLIXICAL  EXPOSITION  OP  THE  MEDICAL  AND  SURGI- 
CAL DISEASES  OF  WOMEN.  In  one  handsome  octavo  volume  with  illustrations.  {Pre- 
paring.) 


CHURCHILL  OX  THE  PUERPERAL  FEVER  AND 
OTHER  DISEASES  PECULIAR  TO  WOMEN.  1  vol. 
8vo.,  pp.  4.')0,  extra  cloth.     $2  oO. 

DEWEES'S  TREATISE  ON  THE  DISEASES  OF  FE- 
MALES. With  illustrations.  Eleventh  Edition, 
with  the  Author's  last  improvements  and  correc- 
tions. In  one  octavo  volume  of  636  pages,  will 
plates,  extra  cloth.     $3  00. 

WEST'S  ENQUIRY  INTO  THE  PATHOLOGICAL 
IMPORTANCE  OF  ULCERATION  OF  THE  OS 
UTERI.     1  vol.  Svo.,  extra  cloth.     $1  2j. 


MEIGS  ON  WOMAN:  HER  DISEASES  AND  THEIR 
RE.MEDIES.  A  Series  of  Lectures  to  his  Class. 
Fourth  and  Improved  Edition.  ]  vol.  Svc,  over 
700  pages,  extra  cloth,  -W  00;  leather,  $6  00. 

MEIGS  ON  THE  NATURE,  SIGNS,  AND  TREAT- 
MENT OF  CHILDIiED  FEVER.  1  vol.  8vo.,  pp. 
36.3,  extra  cloth.     $2  00. 

ASHWELL'S  PRACTICAL  TRE.\TISE  ON  THE  DIS- 
EASES PECULIAR  TO  WOMEN.  Third  American, 
from  the  Third  and  revised  Loudon  edition  I  vol. 
8vo.,  pp.  o2S,  extra  cloth.     $3  50. 


24 


Henry  C.  Lea's  Publications — {Midwifery). 


R 


ODGE  {HUGH  L.),  31.  D., 

Emeritus  Professor  of  Midwifery,  &o  ,  in  the  University  of  Pennsylvania,  &c. 

THE   PRIXCIPLES  AND   PRACTICE   OF   OBSTETPvICS.     Illus- 

trated  with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 

original  photographs,  and  with  numerous  wood-cuts.     In  one  large  and  beautifully  printed 

quarto  volume  of  650  double-columned  pages,  strongly  bound  in  extra  cloth,  $14. 

The  wurk  of  Dr.  Hodge  is  something  more  than  a        "~  ~ 

simple  presentation  of  his  particular  views  in  the  de- 
partment of  Obstetrics;  it  is  something  more  than  an 

ordinary  treatise  on  midwifery  ;  it  is,  in  fact,  a  cyclo- 

pjedia  of  midwifery.     He  has  aimed  to  embody  in  a 

single  volume  the  whole  science  and  art  of  Obstetrics. 

An  elaborate  text  is  combined  with  accurate  and  va- 
ried pictorial  illustrations,  so  that  no  fact  or  principle 

is  left  unstated  or  unexplained. — Am.  Med.  Times, 

Sept.  3,  1864. 
We  shonld  like  to  analyze  the  remainder  of  this 

excellent  work,  but  already  has  this  review  extended 

beyond  our  limited  space.     We  cannot  conclude  this 

notice  without  referring  to  the  excellent  finish  of  the 

work.     In  typography  it  is  not  to  be  excelled  ;  the 

paper  is  superior  to  what  is  usually  afforded  by  onr 

American  cousins,  <)uite  ef[ual  to  the  l1e^t  of  English 

books.     The  engravings  and   lithographs   are  most 

beautifully  executed.     The  work  recommends  itself 

for  its  originality,  and  is  iu  every  way  a  inc>st  valu- 
able addition  to  those  on  the  subject  of  obstetrics. — 

Canada  Med.  Journal,  Oct.  lSti4. 
It  is  very  large,  profusely  and  elegantly  illustrated, 

and  is  fitted  to  take  its  place  near  the  works  of  great 

ob.stetricians.    Of  the  American  works  on  the  subject 

It  is  decidedly  the  best. — Edinh.  Med.  Jour.,  Dec.  "64. 

^*^  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by  mail, 
en  receipt  of  six  cents  in  postage  stamps. 

q^ANNER  [THOMAS  H),  M.  D. 
ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.     First  American 

from  the  Second  and  Enlarged  Engli.-h  Edition.     With  four  colored  plates  and  illustrations 
on  wood.     In  one  hamlsome  octavo  volume  of  about  500  pages,  extra  cloth,  $4  25. 
The  very  thorough  revisioa  the  Work  lias  undergone  I  women  of  to-day,  so  commonly  associated  with  the 


We  have  examined  Professor  Hodge's  work  with 
great  satisfaction ;  every  topic  is  elaborated  most 
fully.  The  views  of  the  author  are  comprehensive, 
and  concisely  stated.  The  rules  of  practice  are  judi- 
cious, and  will  enable  the  practitioner  to  meet  every 
emergency  of  obstetric  complication  with  confidence. 
— Chicago  Med.  Journal,  Aug.  IStil. 

More  time  than  we  have  had  at  our  disposal  since 
we  received  the  great  work  of  Dr.  Hodge  is  necessary 
to  do  it  justice.  It  is  undoubtedly  by  far  the  most 
original,  complete,  and  carefully  composed  treatise 
on  the  principles  and  practice  of  Obstetrics  which  has 
ever  been  issued  from  the  American  press. — Pacijio 
Med.  and  Surg.  Journal,  July,  1864. 

We  have  read  Dr.  Hodge's  book  with  great  plea- 
sure, and  have  much  satisfaction  in  expressing  our 
commendation  of  it  as  a  whole.  It  is  certainly  highly 
instructive,  and  in  the  main,  we  believe,  correct.  The 
great  attention  which  the  author  has  devoted  to  the 
mechanism  of  parturition,  taken  along  with  the  con- 
clusions at  which  he  ha.s  arrived,  p'lint,  we  think, 
conclusively  to  the  fact  that,  in  Britain  at  least,  the 
doctrines  of  Naegele  have  been  too  blindly  received. 
— Glasgow  Med.  Journal,  Oct.  1864. 


has  added  greatly  to  its  practical  value,  and  increased 
materially  its  efficiency  as  a  guide  to  the  student  and 
to  the  young  practitioner. — Am.  Journ.  Med.  Sci., 
April,  ISbS. 

With  the  Immense  variety  of  subjects  treated  of 
and  the  ground  which  they  are  made  to  cover,  the  im- 
possibility of  giving  an  extended  review  of  tliis  truly 
remarkable  work  must  be  apparent.  We  have  not  "a 
single  fault  to  find  with  it,  and  most  heartily  com- 
mend it  to  the  careful  study  of  every  physician  who 
would  not  only  always  be  sure  of  his  diagnosis  of 
pregnancy,  but  always  ready  to  treat  all  the  nume- 
rous ailments  that  are,  unfortunately  for  the  civilized 


function. — If.  ¥.  Med.  Record,  March  16,  1S6S. 

We  have  much  pleasure  in  calling  the  attention  of 
lur  readers  to  the  volume  produced  by  Dr.  Tanner, 
the  second  edition  of  a  work  that  was,  in  its  original 
state  even,  acceptable  to  the  profession.  We  recom- 
mend obstetrical  students,  young  and  old,  to  have 
this  volume  in  their  collections.  It  coutainsnot  only 
a  fair  statement  of  the  signs,  symptoms,  and  diseases 
of  pregnancy,  but  comprises  iu  addition  much  inter- 
esting relative  matter  that  is  not  to  be  found  in  any 
other  work  that  we  can  name. — Edinburgh  Med. 
Journal,  Jan.  1S6S. 


s 


WAYXE  {JOSEPH  GRIFFITHS),  M.  D., 

Physician-Accoucheur  to  the  British  General  Hosjntal,  Ac. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 
MENCING MIDWIFERY  PRACTICE.     Second  American,  from  the  Fifth  and  Revised 
London  Edition,  with  Additions  by  E.  R.  Hutchins,  M.  D.     With  Illustrations.     In  one 
neat  12mo.  volume.     Extra  cloth,  $1  25.     {Now  Read?/.) 
It  is  really  a  capital  little  compendium  of  the  sub- 1  answers   the  purpose.     It  is  not   only  valuable  for 


Jec't,  and  we  recommend  young  priictitiouers  to  buy  it 
and  carry  it  with  them  when  called  to  attend  cases  of 
labor.  They  can  while  away  the  otherwise  tedious 
hours  of  waiting,  and  thoroughly  fix  iu  their  memo- 
ries the  most  important  practical  suggestions  it  con- 
ta,ins.  The  American  editor  has  materially  added  by 
his  notes  and  the  concluding  chapters  to  the  com- 
pleteness and  general  value  of  the  book. — Chicago 
Med.  Journal,  Feb.  1870. 

The  manual  before  us  contains  In  exceedingly  small 
compass — small  enough  to  carry  in  the  pockei — about 
all  there  is  of  obstetrics,  condensed  into  a  nutshell  of 
Aphorisms.  The  illustrations  are  well  selected,  and 
serve  as  excellent  reminders  of  the  conduct  of  labor — 
regular  and  dii&cn\t.— Cincinnati  Lancet,  April,  '70. 

'''bis  Sb  a  most  admirable  lit  tie  work,  and  completely 


young  beginners,  but  no  one  who  is  not  a  proficient 
in  the  art  of  obstetrics  should  be  without  it,  because 
it  condens.'s  all  that  is  necessary  to  know  for  ordi- 
nary midwifery  practice.  We  commend  the  book 
most  favorably. — at.  Louis  Med.  andHurg.  Journal, 
Sept.  10,  1870. 

A  studied  perusal  of  this  little  book  has  satisfied 
us  of  its  eminently  practical  value.  The  object  of  the 
work,  the  author  says,  in  his  preface,  is  to  give  the 
student  a  few  brief  and  practical  directions  respect- 
ing the  management  of  ordinary  cases  of  labor  ;  and 
also  to  point  out  to  him  in  extraordinary  cases  when 
and  how  he  may  act  upon  his  own  re.^ponsibility,  and 
when  he  ought  to  send  for  assistance. — S.  ¥.  Medical 
Journal,  May,  1870. 


w 


INCKEL  (F.).  ~ 

Profe.'^.nor  and  Director  of  the  Gynacolngical  Clinic  in  the  University  of  Jin.i'ock. 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 

MENT  OF  CHILDBED,  for  Students  and  Practitioners.  Translated,  with  the  consent  of 
the  author,  from  the  Second  German  Edition,  by  James  Read  Chadwick,  M  D.  In  one 
octavo  volume.      {Preparuig  ) 


Henry  C.  Lea's  Publications — {Midwifery). 


25 


TlfEIGS  {CHARLES  D.),  M.D., 

•*-^  Lately  Professor  of  Obstetrics,  &o  ,  in  the  Jefferson  Medical  College,  Philadelphia. 

OBSTETRICS:    THE   SCIENCE   AND   THE   ART.     Fifth  edition, 

revised.     With  one  hundred  and  thirty  illustrations.     In  one  beautifully  printed  octavo 
volume  of  760  large  pages.     Extra  cloth,  $6  50;  leather,  $6  50. 

It  is  to  the  student  that  our  author  has  more  par- 
ticularly addressed  himself;  but  to  the  practitiouer 
we  believe  it  would  be  equally  serviceable  as  a  book 
of  reference.     No  work  that  we  have  met  with   so 


thoroughly  details  everything  that  falls  to  the  lot  of 
the  accoucheur  to  perform.     Every  detail,  no  matter 
how  minute   or   how  trivial,  has   found   a  place.— 
Canada  MedicalJournal,  July,  1S67. 
The  original  edition  is  already  so  extensively  and 


favorably  known  to  the  profession  that  no  recom- 
mendation is  necessary  ;  it  is  sutflcieut  to  say,  the 
present  edition  is  very  much  extended,  improved, 
and  perfected.  Whilst  the  great  practical  talents  and 
anlimited  experience  of  the  author  render  it  a  most 
valuable  acquisition  to  the  practitioner,  it  is  so  con- 
densed as  to  constitute  a  most  eligible  and  excellent 
text-book  for  the  student. — Southern  Mtd.  and  Swy. 
Journal,  July,  ISilT. 


PAMSBOTHAM  [FRANCIS  H.),  M.D. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDI- 
CINE AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.     With  additions  by  W.   V.   Keating,  M.  1>., 

.  Professor  of  Obstetrics,  <fec.,  in  the  Jefl'erson  Medical  College,  Philadelphia.  In  one  large 
and  handsome  imperial  octavo  volume  of  660  pages,  strongly  bound  in  leather,  with  raised 
bands;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  test,  containing  in 
all  nearly  200  large  and  beautiful  figures.     $7  00. 

We  will  only  add  that  the  student  will  learn  from  i  To  the  physician's  library  it  is  indispensable,  while 
It  all  he  need  to  know,  and  the  practitioner  will  lind  '  to  the  student,  as  a  text-book,  from  which  'to  extract 
It,  as  a  book  of  reference,  surpassed  by  none  other.—  j  the  material  for  laying  the  foundation  of  an  education 
Stethoscope.  on  obstetrical  science,  it  has  no  superior.— O/iio  Mtd. 

The  character  and  merits  of  Dr.  Ramsbotham's  i  ^"'^  Surg.  Journal. 
work  are  so  well  known  and  thorouglily  established,  When  we  call  to  mind  the  toil  we  underwent  in 
that  comment  is  unnecessary  and  praise  supertiuous.  !  acquiring  a  knowledge  of  this  subject,  we  cannot  but 
The  illustrations,  which  are  numerous  and  accurate,  1  envy  the  student  of  the  present  day  the  aid  which 
are  executed  in  the  highest  style  of  art.  We  cannot  j  this  work  will  afford  him. — Am.  Jour,  of  the  Med. 
too  highly  recommend  the  work  to  our  readers. — St.  Sciences. 
Loius  Med.  and  Surg.  Journal.  I 

/JHURCHILL  [FLEETWOOD),  31. D.,  M.R.I. A. 

ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.    A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.     With  notes  and  additions 
by  D.  Francis  Condie,  M.  D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of  Chil- 
dren,"  &c.     With  one  hundred  and  ninety-four  illustrations.     In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.     Extra  cloth,  $4  00;  leather,  $5  00. 
In  adapting  this  standard  favorite  to  the  wants  of  the  profession  in  the  United  States,  the  editor 
has  endeavored  to  insert  everything  that  his  experience  has  shown  him  would  be  desirable  for  the 
American  student,  including  a  large  number  of  illustrations.     With  the  sanction  of  the  author, 
he  has  added,  in  the  form  of  an  appendix,  some  chapters  from  a  little  "Manual  for  Midwives  and 
Nurses,"  recently  issued  by  Dr.  Churchill,  believing  that  the  details  there  presented  can  hardly 
fail  to  prove  of  advantage  to  the  junior  practitioner.     The  result  of  all  these  additions  is  that  the 
work  now  contains  fully  one-half  more  matter  than  the  last  American  edition,  with  nearly  one- 
half  more  illustrations ;  so  that,  notwithstanding  the  use  of  a  smaller  type,  the  volume  contains 
almost  two  hundred  pages  more  than  before. 

These  additions  render  the  work  still  more  com- 
plete and  acceptable  than  ever;  and  with  the  excel- 
lent style  in  which  the  publishers  have  pi'esented 
this  edition  of  Churchill,  we  can  commend  it  to  the 
profession  with  great  cordiality  and  pleasure. — Cin- 
cinnati Lancet. 

Few  workp  on  this  branch  of  medical  science  are 
equal  to  it,  certainly  none  excel  it,  whether  in  regard 
to  theory  or  practice,  and  in  one  respect  it  is  superior 
to  all  others,  viz.,  in  its  statistical  information,  and 
therefore,  on  these  grounds  a  most  valuable  work  for 
the  physician,  student,  or  lecturer,  all  of  whom  will 
find  in  it  the  information  which  they  are  seeking. — 
Brit.  Am.  Journal. 

The  present  treatise  is  very  much  enlarged  and 
amplified  beyond  the  previous  editions  but  nothing 


has  been  added  which  coald  be  well  dispensed  with. 
An  examination  of  the  table  of  contents  shows  how 
thoroughly  the  author  has  gone  over  the  ground,  and 
the  care  he  has  taken  in  the  text  to  present  the  sub- 
jects in  all  their  bearings,  will  render  ihis  new  edition 
even  moie  necessary  to  the  obstetric  student  than 
were  either  of  the  former  editions  at  the  date  of  their 
appearance.  No  treatise  on  obstetrics  with  which  we 
are  acquainted  can  compare  favorably  with  this,  in 
respect  to  the  aiuount  of  material  which  has  been 
gathered  from  every  source. — Boston  Med.  and  Surg. 
Journal. 

There  is  no  better  text-book  for  students,  or  work 
of  reference  and  study  for  the  practisiug  physician 
than  this.  It  should  adorn  and  enrich  every  medical 
library. — Chicago  Med.  Journal. 


M' 


0NTG0MER7  [W.  F.),  M.D., 

Professor  of  Midwifery  in  the  King\s  and  Queen's  College  of  Physicians  in  Ireland. 

AN  EXPOSITION  OF  THE  SIGNS  AND  SYMPTOMS  OF  PREG- 

NANCY.  With  some  other  Papers  on  Subjects  connected  with  Midwifery.  From  the  second 
and  enlarged  English  edition.  With  two  exquisite  colored  plates,  and  numerous  wood-cuts. 
In  one  very  handsome  octavo  volume  of  nearly  600  pages,  extra  cloth.     $3  75. 


KIGBY'S  SYSTEM  OF  MIDWIFERY.  With  Notes 
and  Additional  lUustrittions.  Second  American 
edition.  One  volume,  octavo,  extra  cloth,  422  pages 
$2  60.  "  I 


DEWEES'S  COMPREHENSIVE  SYSTEM  OF  MID- 
WIFERY. Twelfth  edition,  with  the  author's  last, 
Improvements  and  corrections.  In  one  octavo  vol- 
ume, extra  cloth,  of  6l)0  pages.    $3  60. 


Henry  C.  Lea's  Publications — (Surgery). 


fyROSS  (SAMUEL  D.),  M.D., 

^J'  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

A  SYSTEM  OF  SURGERY:   Pathological,  Diagnostic,  Therapeutic, 

and  Operative.     Illustrated  by  upwards  of  Fourteen  Hundred  Engravings.     Fifth  edition, 
carefully  revised,  and  improved.    In  two  large  and  beautifully  printed  imperial  octavo  vol- 
umes of  about  2300  pages,  strongly  bound  in  leather,  with  raised  bands,  $16.    {Just  Ready.) 
The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.    In  the 
present  revision  no  pains  have  been  spared  by  the  author  to  bring  it  in  every  respect  fully  up  to 
the  day.     To  effect  this  a  large  part  of  the  work  has  been  rewritten,  and  the  whole  enlarged  by 
nearly  one  fourth,  notwithstanding  which  the   price  has  been  kept  at  its  former  very  moderate 
rate.     By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  of  matter  is 
condensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary  octavos. 
This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  binding,  renders 
it  one  of  the  cheapest  works  accessible  to  the  profession.    Every  subject  properly  belonging  to  the 
domain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this  work  may  be  said  to 
have  in  it  a  surgical  library. 


It  must  long  remain  the  most  comprehensive  worli 
on  this  important  part  of  medicine. — Boston  Medical 
and  HurgicalJournal,  March  23,  IStiO. 

We  have  compared  it  with  most  of  our  standard 
works,  such  a.s  those  of  Erichseu,  Miller,  Feigusson, 
Syme,  and  others,  and  we  must,  in  justice  to  our 
author,  award  it  the  pre-eminence.  As  a  work,  com- 
plete in  almost  every  detail,  no  matter  how  minute 
or  trifling,  and  embracing  every  suhject  known  in 
the  principles  and  practice  of  surgery,  we  believe  it 
stands  without  a  rival.  Dr.  Gross,  in  his  preface,  re- 
marks "my  aim  has  been  to  embrace  the  whole  do- 
main of  surgery,  and  to  allot  to  every  subject  its 
legitimate  claim  to  notice;"  and,  we  assure  our 
readers,  he  has  kept  his  word.  It  is  a  work  which 
we  can  most  confidently  recommend  to  our  bretbien, 
for  its  utility  is  becoming  the  more  evident  the  longer 
il  is  upon  the  shelves  of  our  library. — Canada  Med. 
Journal,  September,  186u. 

The  first  two  editions  of  Professor  Gross'  System  of 
Surgery  are  so  well  known  to  the  profession,  and  so 
highly  prized,  ihat  it  would  be  idle  for  us  to  speak  in 
praise  of  this  work. —  Chicago  Medical  Journal, 
September,  1S65. 

We  gladly  indorse  the  favorable  recommendation 
of  the  work,  both  as  regards  matter  and  style,  whicli 
we  made  when  noticing  its  first  appearance. — British 
and  Foreign  Mtdieo-Uhirurgicul  Review,  Oct.  18ti.5. 

The  most  complete  work  that  has  yet  issued  from 
the  press  on  the  science  and  practice  of  surgery. — 
London  Lancet. 

This  system  of  surgery  is,  we  predict,  destined  to 
take  a  commanding  position  in  our  surgical  litera- 
ture, and  be  the  crowning  glory  of  the  author's  well 
earned  fame.  As  an  authority  ou  general  surgical 
subjects,  this  work  is  long  to  occupy  a  pre-eminent 
place,  not  only  at  home,  but  abroad.     We  have  no 


hesitation  in  pronouncing  it  without  a  rival  in  our 
language,  and  equal  to  the  best  systems  of  surgery  in 
any  language. — S.  Y.  Med.  Journal. 

Not  only  by  far  the  best  texi-book  on  the  subject, 
as  a  whole,  within  the  reach  of  American  students, 
but  one  which  will  be  much  more  than  ever  likely 
to  be  resorted  to  and  regaided  as  a  high  authority 
ibroad. — Am.  Journal  Med.  Sciences,  Jan.  IfeOo. 

The  work  contains  everything,  minor  and  major, 
operative  and  diagnostic,  including  mensuration  and 
examination,  venereal  diseases,  and  uterine  manipu- 
lations and  operations.  It  is  a  complete  Thesaurus 
of  modern  surgery,  where  the  student  and  practi- 
tioner shall  not  seek  in  vain  for  what  they  desire.— 
San  Fi-anci,ico  Med.  Press,  Jan.  1865. 

Open  it  where  we  may,  we  find  sound  practical  in- 
formation conveyed  in  plain  language.  This  book  is 
no  mere  provincial  or  even  national  system  of  sur- 
gery, but  a  work  which,  while  very  largely  indebted 
to  the  past,  has  a  strong  claim  on  the  gratitude  of  the 
future  of  surgical  science. — Edinburgh  Med.  Journal, 
Jan.  ]8(Jo. 

A  glance  at  the  work  Is  sufiBci&nt  to  show  that  the 
author  aud  publisher  have  spared  no  labor  in  making 
it  the  most  complete  "System  of  Surgery"  ever  pub- 
lished in  any  country. — tit.  Louis  Med.  and  Surg. 
Journal,  April,  Ibb.i. 

A  system  of  surgery  which  we  think  unrivalled  in 
our  language,  and  which  will  indelibly  associate  his 
name  with  surgical  science.  Aud  what,  in  our  opin- 
ion, enhances  the  value  of  the  worij  is  that,  while  the 
practising  surgeon  will  tiud  all  that  he  requires  in  it, 
it  is  at  the  same  time  one  of  the  most  valuable  trea- 
tises which  can  be  put  into  the  hands  of  the  student 
seeking  to  know  the  principles  aud  practice  of  this 
branch  of  the  profession  which  he  designs  subse- 
quently to  follow. — Tim  Brit.  Am.Journ.,  Montreal. 


UY  THE  SAME  AUTHOR. 

A   PRACTICAL    TREATISE    ON    FOREIGN    BODIES   IN   THE 

AIR-PASSAGES.     In  1  vol.  8vo.  cloth,  with  illustrationa.     pp.  468.     $2  76. 


SKET'S  OPERATIVE  S0RGEKT.     In  1    vol.    8vo. 

cloth,  of  over  tiSO  pages ;  with  about  100  wood-cuts. 

$3  2.5. 
COOPER'S  LECTURES  ON  THE  PRINCIPLES  AND 

Pk ACTiCE  OF  Shrgert.  In  1  vol.  Svo.  cloth,  750  p.  $2. 


GIB.SON'S  INSTITUTES  AND  PRACTICE  OF  SUE- 
OERV.  Eighth  edition,  impr.>ved  and  altered.  With 
thirty-four  plates.  In  two  haudsome  octavo  vol- 
umes, about  1000 pp., leather, raised  hands.  !|j6  50, 


AJILLER  [JAMES], 

•^'-^  Late  Professor  of  Surgery  in  the  University  of  Edinburgh,  &c, 

PRINCIPLES  OF  SURGERY.     Fourth  American,  from  the  third  and 

revised  Edinburgh  edition.     In  one  large  and  very  beautiful  volume  of  700  pages,  with 
two  hundred  and  forty  illustrations  on  wood,  extra  cloth.     %'6  lb. 
DY  THE  SAME  AUTHOR.  

THE   PRACTICE   OF   SURGERY.     Fourth  American,  from  the  last 

Edinburgh  edition.  Revised  by  the  American  editor.  Illustrated  by  three  hundred  and 
sixty-four  engravings  on  wood.  In  one  large  octavo  volume  of  nearly  700  pages,  extra 
cloth.     |3  75.  J  f  e,     : 

^ARGENT  {F.  W.),  M.D. 

ON  BANDAGING  AND  OTHER  OPERATIONS  OF  MINOR  SUR- 

GERY,  New  edition,  with  an  additional  chapter  on  Military  Surgery.  One  handsome  royal 
12mo.  volume,  of  nearly  400  pages,  with  184  wood-cuts.     Extra  cloth,  $1  lb. 


Henry  C.  Lea's  Publications — (Surgery). 


21 


ASHHURST  {JOHiV,  Jr.),  M.D., 

Surgeon  to  the  Episonpol  Hsnpital,  Philadelphia. 

THP]    PRINCIPLES   AND    PRACTICE   OF    SURGERY.     In  one 

very  large  and  handsome  octavo  volume  of  about  1000  page?,  with  nearly  550  illustrations, 
extra  cloth,  $6  50;  leather,  raised  bands,  $7  60,      {Just  Isxued.) 

The  object  of  the  author  has  been  to  present,  within  as  condensed  a  compass  as  possible,  a 
complete  treatise  on  Surgery  in  all  its  branches,  suitable  both  as  a  test-book  for  the  student  and 
a  work  of  reference  for  the  practitioner.  So  much  has  of  late  years  been  done  for  the  advance- 
ment of  Surgical  Art  and  Science,  that  there  seemed  to  be  a  want  of  a  work  which  should  present 
the  latest  aspects  of  every  subject,  and  which,  by  its  American  character,  should  render  accessible 
to  the  profession  at  large  the  experience  of  the  practitioners  of  both  hemispheres.  This  has  been 
the  aim  of  the  author,  and  it  is  hoped  that  the  volume  will  be  found  to  fulfil  its  purpose  satisfac- 
torily. The  plan  and  general  outline  of  the  work  will  be  seen  by  the  annexed 
CONDENSED  SUMMAEY  OF  CONTENTS. 

Chapter  I.  Inflammation.  II.  Treatment  of  Inflammation.  III.  Operations  in  general  : 
Anse.sthetics.  IV.  Minor  Surgery.  V.  Amputations.  VI.  Special  Amputations.  VII.  Effects 
of  Injuries  in  General  :  Wounds.  VIII.  Gunshot  Wounds.  IX.  Injuries  of  Bloodvessels.  X. 
Injuries  of  Nerves,  Muscles  and  Tendons,  Lymphatics,  Bursae,  Bones,  and  Joints.  XI.  Fractures. 
Xil.  Special  Fractures.  XIII.  Dislocations.  XIV.  Effects  of  Heat  and  Cold.  XV.  Injuries 
of  the  Head.  XVI.  Injuries  of  the  Back.  XVII.  Injuries  of  the  Face  and  Neck.  XVIII. 
Injuries  of  the  Chest.  XIX.  Injuries  of  the  Abdomen  and  Pelvis.  XX.  Diseases  resulting  from 
Inflammation.  XXI.  Erysipelas.  XXII.  Pyaemia  XXIIL  Diathetic  Diseases:  Struma  (in- 
cluding Tubercle  and  Scrofula) ;  Rickets.  XXIV.  Venereal  Diseases  ;  Gonorrhoea  and  Chancroid. 
XXV.  Venereal  Diseases  continued  :  Syphilis.  XXVI.  Tumors.  XXVII.  Surgical  Diseases  of 
Skin,  Areolar  Tissue,  Lymphatics,  Muscles,  Tendons,  and  Bur.sse.  XXVIII.  Surgical  Disease 
of  Nervous  System  (including  Tetanus).  XXIX.  Surgical  Diseases  of  V^ascuiar  System  (includ- 
ing Aneurism).  XXX.  Diseases  of  Bone.  XXXI.  Diseases  of  Joints.  XXXII.  Excisions. 
XXXIII.  Orthopaedic  Surgery.  XXXIV.  Diseases  of  Head  and  Spine.  XXXV.  Diseases  of  the 
Eye.  XXXVI.  Diseases  of  the  Ear.  XXXVII.  Diseases  ot  the  Face  and  Neck.  XXXVIII. 
Diseases  of  the  Mouth,  Jaws,  and  Throat.  XXXIX.  Diseases  of  the  Breast.  XL.  Hernia.  XLI. 
Special  Herniae.  XLII.  Diseases  of  Intestinal  Canal.  XLIII.  Diseases  of  Abdominal  Organs, 
and  various  operations  on  the  Abdomen.  XLIV.  Urinary  Calculus.  LXV.  Diseases  of  Bladder 
and  Prostate.      XLVI.   Diseases  of  Urethra.      XLVII.  Diseases  of  Generative  Organs.     Index. 


Its  author  has  evideully  tested  the  writings  and 
experiences  of  the  pitsl  and  present  in  the  crucible 
of  a.  careful,  analytic,  and  honorable  mind,  and  faith- 
fully endeavored  to  bring  his  work  np  to  the  level  of 
ttie  highest  standard  of  practical  surgery  He  is 
fraulv  and  detiuite,  and  gives  us  opinions,  and  gene- 
rally sound  ones,  instead  of  a  mere  resume  of  the 
opinions  of  others  He  is  conservative,  but  not  hide- 
bound by  authority.  His  style  is  clear,  elegant,  and 
scholarly.  The  wi  rk  is  an  admirable  text  book,  and 
a  useful  book  of  reference  It  is  a  credit  to  American 
piofes.sional  literature,  and  one  of  the  first  ripe  fruits 
of  the  soil  fertilized  by  the  blood  of  our  late  unhappy 
war.— iV^.  r.  Med.  Record,  Feb.  1,  1872. 


Indeed,  the  work  as  a  whole  must  be  regarded  as 
an  excellent  and  concise  e.xpoueut  of  modern  sur- 
gery, and  as  such  it  will  be  found  a  valuable  text- 
book for  the  student,  and  a  useful  book  of  reference 
for  the  general  practitioner. — A'.  ¥.  Med.  Journal, 
Feb.  1872. 

It  gives  us  great  pleasure  to  call  the  attention  of  the 
profession  to  this  excellent  work.  Our  knowledgeof 
its  talented  and  accomplished  author  led  us  to  expect 
from  him  a  very  valuable  treatise  upon  subjects  to 
which  he  has  repeatedly  given  evidence  of  having  pro- 
fitably devoted  much  liuieand  labor,  and  we  are  in  no 
way  ditappointed.— P/((.'a.  Med.  Times,  Feb.  1,  1872. 


piRRIE  (  WILLIAM),  F.  R.  S.  E., 

-*-  Profe..i:sor  of  Surgery  in  the  University  of  Aberdeen. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.    Edited  by 

John  Neill,  M.  D.,  Professor  of  Surgery  in  the  Penna.  Medical  College,  Surgeon  to  the 
Pennsylvania  Hospital,  &c.  In  one  very  handsome  octavo  volume  of  760  pages,  with  3]  8 
illustrations,  extra  cloth.     $3  75. 


H 


A  MILTON  {FRANK  K),  M.D., 

Professor  of  Fractures  and  Dislocntions,  Ac,  in  Bellemi,e  Hasp.  Med.  College,  New  York. 

A  PRACTICAL  TREATISE   ON   FRACTURES  AND   DISLOCA- 

TIONS.  Fourth  edition,  thoroughly  revised.  In  one  large  and  handsome  octavo  volume 
ol  nearly  800  pages,  with  several  hundred  illustrations.  Extra  cloth,  $6  75  ;  leather,  $6  75. 
{Just  Issued. ' 

rable  treatise,  which  we  have  always  considered  the 
most  complete  and  reliable  work  on  the  subject.  As 
a  whole,  the  work  is  without  an  equal  in  the  litera- 
ture of  the  profession. — Busto7i  Med.  and  Surg. 
Joarn.,  Oct.  12,  1871. 


It  is  not,  of  course,  our  intention  to  review  in  ex- 
le.mo,  Hamilton  on  "Fractures  and  Dislocations." 
Eleven  years  ago  such  review  might  not  have  been 
out  of  place  ;  to-day  the  work  is  au  authority,  so  well, 
so  generally,  and  so  favorably  known,  that  it  only 
remains  for  the  reviewer  to  say  that  a  new  edition  is 
just  out,  and  it  is  better  than  either  of  its  predeces- 
sors.— Cincinnati  Clinic,  Oct.  14,  1871. 

Undoubtedly  the  best  work  on  Fractures  and  Dis- 
locations in  the  English  language.  —  Cincinnati  Med. 
Ropertovy,  Oct.  1&71. 

We  have  once  more  before  us  Dr.  Hamilton's  admi- 


It  is  unnecessary  at  this  time  to  commend  the  book, 
except  to  such  as  are  beginners  in  the  study  of  this 
particular  branch  of  surgery.  Every  practical  sur- 
geon in  this  countrj'  and  abroad  knows  of  it  as  a  most 
trustworthy  guide,  and  one  which  they,  in  common 
with  us,  would  unqualifiedly  recommend  as  the  high- 
e.st  authority  in  any  language. — N.  Y.  Med.  Record, 
Oct   16,  1871. 


M 


ORLAND  [W.   IF.),  M.D. 

DISEASES  OF  THE  URINARY  ORGANS;  a  Compendium  of  their 

Diagnosis,  Pathology,  and  Treatment.     With  illustrations      In  one  large  and  haudsoiue 
vKJtavo  volume  of  about  600  pages,  extra  cloth.     $3  50. 


28  Henry  C.  Lea's  Publications — (Surgery). 


JPRICHSEN  [JOHN  E.), 

J2J  Prrifpiisor  of  Surgery  in  University  College,  Loyidon,  etc. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Sur- 
gical Injuries,  Diseases,  and  Operations.  Revised  by  the  author  from  the  Sixth  and 
enlarged  English  Edition.  Illustrated  by  over  seven  hundred  engraving.^  on  wood.  In 
two  large  and  beautiful  octavo  volumes  of  over  1700  pages,  extra  cloth,  $9  00  ;  leather, 
$11  00.      (Just  Ready.) 

Autlior^s  Preface  to  the  New  American  Edition. 

"  The  favorable  reception  with  which  the  '  Science  and  Art  of  Surgery'  has  been  honored  by  the 
Surgical  Profession  in  the  United  State.s  of  America  has  been  not  only  a  source  of  deep  gratifica- 
tion and  of  just  pride  to  me,  but  has  laid  the  foundation  of  many  professional  friendships  that 
are  amongst  the  agreeable  and  valued  recollections  of  my  life. 

"I  have  endeavored  to  make  the  present  edition  of  this  work  more  deserving  than  its  predecessors 
of  the  favor  that  has  been  accorded  to  them.     In  consequence  of  delays  that  have  unavoidably 
occurred  in  the  publication  of  the  Sixth  British  Edition,  time  has  been  afforded  to  me  to  add  to  this 
one  several  p^iragraphs  which  I  trust  will  be  found  to  increase  the  practical  value  of  the  work." 
LoNuos,  Oct.  1^72. 

On  no  former  edition  of  this  work  has  the  author  bestowed  more  pains  to  render  it  a  complete  and 
satisfactory  exposition  of  British  Surgery  in  its  modern  aspects.  Every  portion  has  been  sedu- 
lously revised,  and  a  large  number  of  new  illustrations  have  been  introduced.  In  addition  to  the 
material  thus  added  to  the  English  edition,  the  author  has  furnished  for  the  American  edition  such 
material  as  has  accumulated  since  the  pas.-age  of  the  sheets  through  the  press  in  London,  so  that 
the  work  as  now  presented  to  the  American  profession,  contains  his  latest  views  and  experience. 

The  increase  in  the  size  of  the  work  has  seemed  to  render  necessary  its  division  into  two  vol- 
umes. Great  care  has  been  exercised  in  its  typographical  executicm,  and  it  is  confidently  pre- 
sented as  in  ever3'  respect  worthy  to  maintain  the  high  reputation  which  has  rendered  it  a  stand- 
ard authority  on  this  department  of  medical  science. 

These  are  only  a  few  of  the  points  ia  which  the  states  in  hia  preface,  theyare  not  confined  toanyone 
present  edition  of  Mr.  Erich.sen's  work  surpasses  ita  purlion,  but  are  dixtributed  generally  through  the 
predecessors.  Throughout  there  is  evidence  of  a  subjects  of  which  the  work  treats.  Certainly  oue  of 
laborious  care  and  solicitude  in  seizing  the  passing  I  the  most  valuable  sections  of  the  book  .seems  to  us  to 
knowledge  of  the  day,  which  reflects  the  greatest  be  that  which  treats  of  the  diseases  of  the  arteries 
ciedit  on  the  author,  and  much  enhances  the  value  and  theoperative  proceedings  which  they  necessitate, 
of  his  work.  We  can  only  admire  the  industry  wliich  |  In  few  text-books  is  so  much  carefully  arranged  in- 
has  enabled  Mr.  Erichsen  thus  to  succeed,  amid- the  formation  collected. — London  Med.  Times  and  Gaz., 
distractionsof  active  practice,  in  producing  emphatic-  '  Oct.  26,  iS72. 

allyTHEbookof  reference  and  study  for  British  piac- I      T,jg  entire  work,  coraplpte,  as   the  great  English 
fnxouers  ot  snrgeiy.— London  Lancet,  Oct.  20,  1S72.     [  treatise  on  Surgery  of  our  own  time,  is,  we  can  assure 

Considerable  changes  have  been  made  in  this  edi-  '  our  readers,  equally  well  adapted  for  the  most  junior 
tion,  aud  nearly  a  liundi-ed  new  illustrations  have  ;  student,  and,  asa  book  of  reference,  for  the  advanced 
bicn  added.    It  is  dillicult  in  a  small  compass  to  point     practitioner. — Dahlin  Quarterly  Journal. 
out  the  alterations  and  additions;  foe,  as  the  author  i 


UY  THE  SAME  AUTHOR.     (Just  Issued.) 

ON   RAILWAY,    AND    OTHER    INJURIES    OF    THE    NERYOUS 


SYSTEM.     In  a  small  octavo  volume.     Extra  cloth,  $1  00. 


D 


RUITT  {ROBERT),  M.R.C.S.,  §-c. 

THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  new  and  revised  American,  from  the  eighth  enlarged  and  improved  London  edition     Illus- 
trated with  four  hundred  and  thirty-two  wood  engravings.     In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages.    Extra  cloth,  $4  00 ;  leather,  $5  00. 
All  that  the  surgical  student  or  practitioner  could     perspicuously,  as  to  elucidate  every  important  topic, 
desire. — Dublin  Quarterly  Journal.  j  The  fact  that  twelve  editions  h.ave  already  been  called 

for,  in   these   days  of  active  competition,  would  of 

It  is  a  most  admirable  book.     We  do  not  know  !  itself  show  it   to  possess   marked   superiority.     We 

when  we  have  examined  one  with  more  pleasure. —  j  bare  examined  the  book  most  thoroughly,  and  can 

Boston  Med.  and  Surg.  Journal.  iay   that   this  success  is  well    merited.     His  book, 

moreover,  possesses   the  inestimable  advantages  of 
In  Mr.  Druitt's  book,  though  containing  only  some  |  having  the  subjects  perfectly  well  arranged  and  clag- 
seven  hundred  pages,  both    the   principles  and  the  I  <ified,  and  of  being  written  in  a  style  at  once  clear 
practice  of  surgery  are  treated,  and  so  clearly  and  !  ind  succinct.— ^r/i.  Journal  of  Med.  Sciences. 


A  SET  ON  [T.  J.). 


ON  THE   DISEASES,'  INJURIES,  AND  MALFORMATIONS   OF 

THE  RECTUM  AND  ANUS:  with  remarks  on  Habitual  Constipation.  Second  American, 
from  the  fourth  and  enlarged  London  edition.  With  handsome  illustrations.  In  one  very 
beautifully  printed  octavo  volume  of  about  .300  pages.     $3  25. 


niGELO  W  {HE NET  J.).  31.  D., 

-*-'  Pro/f.y.<!or  of  Surgery  in  the  Ma.ssachiisetts  Med.  College, 

ON   THE   MECHANISM   OF    DISLOCATION  AND  FRACTURE 

OF  THE  HIP.  With  the  Reduction  of  the  Dislocation  by  the  Flexion  Method.  With 
numerous  original  illustrations.  In  one  very  handsome  octavo  volume.  Cloth.  $2  50. 
(Lately  Issued.) 


Henry  C.  Lea's  Publications — (Surgery).  29 

T^RFANT  {THOMAS),  F.R.C.S., 

■*--'  Surgeon  to  Guy''s  Ho-ijiifal. 

THE   PRACTICE    OF   SURGERY.     With  over  Five  Hunclred  En- 

gravino;s  on  Wood.     In  one  large  and  very  handsome  octavo  volume  of  nearly  1000  pages, 

extra  cloth,  $6  25  ;  leather,  raised  bands,  $7  25.  (Just  Reidy.) 
The  distinguished  reputation  of  the  author  and  the  extended  experience  which  he  has  enjoyed  as 
surgeon  to  one  of  the  largest  of  the  London  hospitals,  are  an  earnest  of  the  value  of  his  labors. 
Though  entitled  a  "  Practice  of  Surgery,"  it  ^¥iil  be  seen  by  the  subjoined  summary  of  the  contents 
that  it  is  by  no  means  confined  to  operative  surgery,  but  that  it  presents  also  a  view  of  the  prin- 
ciples which  should  guide  the  surgeon  in  his  daily  prrtcticc.  Nearlj-  all  of  the  very  full  series  of 
illustrations  have  been  prepared  expressly  for  the  work. 

SXJI^/IIvI.A.E,^^^'  OF  coisrTEisrTS. 
Introduction. — i.  On  Repair  and  Inflainmntion.  ii.  On  Traumatic  Fever,  Septicaamin,  and  Py- 
aemia. III.  On  Trismus  and  Tetanus,  iv.  Delirium  Tremens,  v.  Contusions:  Wounds  of  the  Scalp, 
Blood  Tumors,  Osteitis,  vi.  Injuries  of  the  Cranium,  vii.  Concussion  of  the  Brain.  Tiir.  Injuries 
of  the  Brain  and  its  Membranes,  complicating  Fracture,  ix.  Compression  of  the  Brain,  x.  Re- 
sults of  Injuries  to  the  Head.  xi.  On  Fractures  of  the  Skull,  xii.  The  Operation  of  Trephining, 
xiii.  Diseases  of  the  Scalp  and  Cranium,  xiv.  Spina  Bifida,  xv.  Injuries  of  the  Spine,  xvi. 
lutra-Spinal  Inflammation,  Spinal  Paralj'sis,  Railway  Concussion,  xvii.  Fractures,  Diflocations, 
and  Wounds  of  the  Spine,  xviii.  Curvature  of  the  Spine,  xix.  Injuries  and  Diseases  of  the  Nerves. 
XX.  Surgical  Afrecti(ms  of  the  Nose.  xxi.  Surgical  Affections  of  Larynx  and  Trachea,  xxii.  Sur- 
gery of  the  Chest,  xxiii.  Wounds  of  the  Heart,  xxiv.  Diseases  of  the  Arteries,  xxv.  Aneurism, 
xxvr.  Ligature  of  Arteries,  xxvii.  Injuries  and  Diseases  of  the  Veins,  xxviir.  Afl'eetions  of  the 
Lips,  etc.  XXIX.  Diseases  of  the  Jaws,  etc.  xxx.  AfJ'ections  of  the  Pharynx,  xxxi.  Injuries  of 
the  Abdomen,  xxxii.  Hernia,  xxxiii.  Varieties  of  Herniae.  xxxiv.  Trusses,  xxxv.  Surgery  of 
the  Anus,  xxxvi.  Diseases  of  the  Integuments  :  Wounds,  xxxvii.  Poisoned  Wounds,  xxxviii. 
Burns,  xxxix.  Skin  Grafting,  xl.  Boils,  etc.  XLi.  Gangrene,  etc.  XLii.  Ulcers.  XLiii.  Mor- 
tification. XLiv.  Erysipelas.  XLV.  Diseases  of  the  Lymphatics,  xlvi.  Diseases  of  the  Kidney. 
XLVii.  Diseases  of  the  Bladder,  xlviii.  Diseases  of  the  Prostate,  xlix.  Urinary  Deposits,  l. 
Stone  in  the  Bladder.  Li.  Lithotrity.  lii.  Lithotomy,  liii.  Stone  in  the  Female  Bladder,  liv. 
Stricture  of  the  Urethra,  lv.  Retention  of  Urine,  lvi.  Aftections  of  the  Penis.  LVii.  Hgemato- 
cele,  etc.  LViii.  Diseases  of  the  Testicle.  lix.  Sterility.  LX.  Affections  of  the  Female  Geni- 
tals. LXI.  Ovariotomy,  lxii.  Venereal  Disease,  lxiii.  Syphilis,  lxit.  Tumors,  lxv.  Anatomy 
of  Tumors,  lxvi.  Tumors  of  the  Breast,  lxvii.  Diseases  of  the  Thyroid  Gland.  Lxvni.  Wounds 
of  the  Joints,  lxix.  Dislocations,  lxx.  Dislocations  of  the  Upper  Extremity.  LXXi.  Disloca- 
tions of  the  Lower  Extremity,  lxxii.  Pathology  of  Joint  Diseases,  lxxiii.  Diseases  of  Special 
Joints.  Lxxiv.  Treatment  of  Joint  Disease.  Lxxv.  E.xcision  and  Amputation  in  Joint  Disease. 
Lxxvi.  Osteo-arthritis.  lxxvii.  Diseases  of  the  Bones,  lxxviii.  Tumors  of  Bono,  lxxix.  Frac- 
tures. Lxxx.  Fractures  of  the  Upper  Extremity,  lxxxi.  Fractures  of  the  Lower  Extremity. 
Lxxxii.  Complicated  Fractures,  lxxxiii.  Gunshot  Injuries,  lxxxiv.  Feigned  and  Hysterical  Dis- 
ease. Lxxxy.  Affections  of  the  Muscles  and  Tendons,  lxxxvi.  Ganglions,  lxxxvii.  Orthopaedic 
Surgery,  lxxxviii.  Ansesthetics.  lxxxix.  Shock,  xc.  Amputation,  xci.  Special  Amputations. 
xcii.  Elephantiasis,     xciii.  Affections  of  the  External  Ear.     xciv.  Parasites. 


T^/'ELLS  [J.  SOELBERG), 

'  '  Professor  of  Ophthalmology  in  King's  College  Hospital,  &c. 

A    TREATISE    ON    DISEASES    OF    THE    EYE.      First  American 

Edition,  with  additions  ;  illustrated  with  216  engravings  on  virood,  and  six  colored  plates. 
Together  with  selections  from  the  Test-types  of  Jaeger  and  Snellen.  In  one  large  and 
very  handsome  octavo  volume  of  about  750  pages :  extra  cioth,  $5  00 ;  leather,  $6  00. 
{Lately  Issued.) 

Ill  this  respect  the  work  before  ns  is  of  much  more  [  mend  it  to  all  who  desire  to  consult  a  really  good 
service  to  the  general  practitioner  than  those  heavy  j  work  on  ophthalmic  science.  The  American  edition 
compilations  which,  in  giving  every  person's  views,  I  of  Mr. Wells'  treatise  was  superintendfd  in  its  passage 


too  often  neglect  to  specify  those  which  are  most  in 
accordance  with  the  author's  opinions,  or  in  general 
acceptance.  We  have  no  hesitation  in  recommending 
tills  treatise,  as,  on  the  whole,  of  all  Euglijh  works 
on  the  subject,  the  one  best  adapted  to  the  wants  of 
the  general  'pva.ciilion&t .  —  Edinb ar gh  Mud.  Journal, 
March,  1870. 

A  treatise  of  rare  merit.  It  is  practical,  compre- 
hensive, and  yetconcise.  Upon  those  subjects  usually 
found  difficult  to  the  student,  he  has  dwelt  at  length 
and  entered  into  full  explanation.  After  a  careful 
perusal  of  its  contents,  we  can  unhesitatingly  corn- 


through  the  press  by  Dr.  I.  Minis  Hays,  who  has 
added  some  notes  of  his  own  where  it  seemed  desira- 
ble. He  has  ahso  introduced  more  than  one  hundred 
new  additional  wood-cuts,  and  added  selections  from 
the  test-types  of  Jaeger  and  of  Snellen. — Leavenworth 
Med.  Herald,  Jan.  1S70. 

Without  doubt,  one  of  the  best  works  upon  the  sub- 
ject which  has  ever  been  published  ;  it  is  complete  on 
the  subject  of  which  it  treats,  and  is  a  necessary  work 
for  every  physician  who  attempts  to  treat  diseases  of 
the  eye. — Dominion  Med.  Journal,  Sept.  lStS9. 


L 


A  WSON  [GEORGE).  F.  R.  C.  S.,  Engl, 

Assistant  Surgeon  to  the  Royal  London  Ophthahiiic  Hospital,  Moorfield-i,  &c. 

INJURIES  OF  THE  EYE,  ORBIT,  AND  EYELIDS:  their  Imme- 

diate   and  Remote  Effects.      With  about  one  hundred  illustrations.     In  one  very  hand- 
some octavo  volume,  extra  cloth,  $3  50. 

It  is  an  admirable  practical  book  in  the  highest  and  best  sense  of  the  phrase. — London  Medical  Times 
and  Gazette,  May  18,  1867. 


30  Hbnet  C.  Lea's  Publications— (/Swrgrert/,  (&c.). 


T  A  URENCE  {JOHN  Z.),  F.  R.  C.  S., 

Editor  of  the  Ophthalmic  Review,  &c. 

A  HANDY-BOOK  OF   OPHTHALMIC    SURGERY,  for  the  use  of 

Practitioners.     Second  Edition,  revised  and  enlarged.     With  numerous  illustrations.     In 
one  very  handsome  octavo  volume,  extra  cloth,  $3  00.     [Lately  Issued.) 
For  those,  hnwever,  who  must  assume  the  care  of    tion  of  the  optical  defects  of  the  eye,  the  publisher 
diseases  and  iujuries  of  the  eye,  and  who  are  too  ,  has  given  increased  value  by  ihe  addition  of  several 


much  pressed  for  time  to  study  the  classic  work 
the  subject,  or  those  recently  published  by  Stellwag, 
Wells,  Bader,  and  others,  Mr.  Laurence  will  prove  a 
safe  and  trustworthy  guide.  He  has  described  in  this 
edition  those  novelties  which  have  secured  the  confi- 
dence of  the  profession  since  Ihe  appearance  of  his 
last.    To  the  portion  of  the  book  devoted  to  a  descrip- 


pages  of  Snellen's  lest-types,  »o  generally  used  to  test 
the  acuteness  of  vision,  and  which  are  difficult  to  ob- 
tain in  this  country.  The  volume  has  been  couside- 
rably  enlarged  and  improved  by  (he  revision  and  ad- 
ditions of  its  author,  expressly  for  the  American 
edition. — Am.  Juurn.  Med.  Sciencei,  Jan.  1S70. 


jyALES  [PHILIP  S.),  M.  D.,  Surgeon  U.  S.  N. 
MECHANICAL  THERAPEUTICS:  a  Practical  Treatise  on  Surgical 

Apparatus,  Appliances,  and  Elementary  Operations  :    embracing  Minor  Surgery,  Band- 
aging, Orthopraxy,  and  the  Treatment  of  Fractures  and  Dislocations.     With  six  hundred 
and  forty-two  illustrations  on  wood.     In  one  large  and  handsome  octavo  volume  of  about 
700  pages:  extra  cloth,  $5  75;  leather,  $6  75. 
A  Naval  Medical  Board  directed  to  examine  and  report  upon  the  merits  of  this  volume,  officially 
states  that  "  it  should  in  our  opinion  become  a  standard  work  in  the  hands  of  every  naval  sur- 
geon;" and  its  adoption  for  use  in  both  the  Army  and  Navy  of  the  United  States  is  sufficient 
guarantee  of  its  adaptation  to  the  needs  of  every-day  practice. 


rr HO  MP  SON  {SIR  HENRY), 

-*•  Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital. 

LECTURES  OX  DISEASES  OF  THE  URINARY  ORGANS.    With 

illustrations  on  wood.     In  one  neat  octavo  volume,  extra  cloth.     $2  25. 

These  lectures  stand  the  severe  test.     They  are  in-  on  which  Sir  Henry  Thompson  speaks  with  more  aa- 

atructive  without  being  tedious,  and  simple  without  thority  than  that  iu  which  he  has  specially  gathered 

being  diffuse;  and  they  include  many  of  those  prac-  his  laurels;  in  addition  to  this,  the  conversational 

tical  hints  so  useful  for  the  student,  and  even  more  style  of  instruction,  which  is  retained  in  these  printed 

valuable  to  the  young  practitioner. — Edinburgh  Med.  lectures,  gives  them  au  attractiveness  which  a  sys- 

Jotirnal,  April,  lSt>9.  tematic  treatise  can  never  possess. — London  Medical 

Veryfew  words  of  ours  are  necessary  to  recommend  Times  and  Gazette,  April  'Zi,  1809. 
these  lectures  to  the  profession.     There  is  no  subject 


JDF  THE  .SAME  AUTHOR. 

ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE. OF 

THE  URETHBA  AND  URINARY  FISTULiE.  With  plates  and  wood-cuts.  From  the 
third  and  revised  English  edition.  In  one  very  handsome  octavo  volume,  extra  cloth  $3  50. 
{Lately  Published.) 

This  classical  work  has  so  long  been  recognized  as  a  standard  authority  on  its  perplexing  sub- 
jects that  it  should  be  rendered  accessible  to  the  American  profession.  Having  enjoyed  the 
advantage  of  a  revision  at  the  hands  of  the  author  within  a  few  months,  it  will  be  found  to  present 
hi.s  latest  views  and  to  be  on  a  level  with  the  most  recent  advances  of  surgical  science. 

With  a  work  accepted  as  the  authority  upon  the  I  ably  known  by  the  profession  as  this  before  us,  must 
hubjscts  of  which  it  treats,  an  extended  notice  Would  |  create  a  demand  for  it  from  those  who  would  keijp 
be  a  work  of  supererogation.  The  simple  announce-  I  themselves  well  up  in  this  department  of  Surgery  — 
uieut  of  another  edition  of  a  work  so  well  and  lavor-  |  ,SY.  Louis  Med.  Archives  feb   1S70 


rPAYLOR  {ALFRED  S.),  M.D., 

■'-  Lecturer  on  Mrd.  Jurisp.  and  Chemistry  in  Guy's  Hospital. 

MEDICAL  JURISPRUDENCE.     Seventh  American  Edition.     Edited 

by  John  J.  Reese,  M.D.,  Prcf.  of  Med.  Jurisp.   in  the  Univ.  of  Petin.     In  one  large 
octavo  volume.      (Prepari)ig.) 

The  present  edition  of  this  valuable  manual  is  a  I  partment  of  medicine  for  students  and  the  general 
great  improvement  on  those  which  have  preceded  it  practitioner  in  OMrUyxgyi>>.s&.— Boston  Med.  a7,d  Surg. 
It  makes  thus  by  far  the  best  guide-book  in  this  de-  |  Journal,  Dec.  27,  1866. 


J^  T  THE  SA ME  A  UTHOR.     {Nearly  Ready. ) 

THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURISPRU- 
DENCE. Second  Edition,  Revised,  with  numerous  Illustrations.  In  two  very  large 
octavo  volumes. 

This  great  work  is  now  recognized  in  England  as  the  fullest  and  most  authoritative  treatise  on 
every  department  of  its  important  subject.  In  laying  it,  in  its  improved  form,  before  the  Ameri- 
can protession,  the  publisher  trusts  that  it  will  assume  the  same  position  in  this  country 


Henry  C.  Lea's  Publications— (Psj/cAoZogr^caZ  Medicine,  &c.).      31 


rpUKE  [DANIEL  HACK),  M.D., 

-*-  Joint  author  of  "  The  Manual  of  Psychological  Medicine,'^  *c. 

ILLUSTRATIONS  OF  THE  INFLUENCE  OF  THE  MIND  UFON 

THE  BODY  IN  HEALTH  AND  DISEASE.  Designed  to  illustrate  the  Aution  of  t'.ie 
Imagination.  In  one  handsome  octavo  volume  of  416  pages,  extra  c'.oth,  $:3  25.  {Now 
Keady.) 

The  object  of  the  author  in  this  work  has  been  to  show  not  only  the  effect  of  the  mind  in  caus- 
ing and  intensifying  disease,  but  also  its  curative  influence,  and  the  use  which  may  be  made  of 
the  imagination  and  the  emotions  as  therapeutic  agents.  Scattered  facts  bearing  upon  this  sub- 
ject have  long  been  familiar  to  the  profession,  but  no  attempt  has  hitherto  been  made  to  collect 
and  systematize  them  so  as  to  render  them  available  to  the  practitioner,  by  establishing  the  seve- 
ral phenomena  upon  a  scientific  basis.  In  the  endeavor  thus  to  convert  to  the  use  of  legitimate 
medicine  the  means  which  have  been  employed  so  successfully  in  many  systems  of  quackery,  the 
author  has  produced  a  work  of  the  highest  freshness  and  interest  .as  well  as  of  permanent  value. 

T>LANDFORD  [G.  FIELDING),  M.  D.,  F.  R.  C  P., 

J-'  Lecturer  on  Psychological  Medicine  at  the  School  of  St.  George's  Hospital,  Ac. 

INSANITY  AND  ITS  TREATMENT:  Lectures  on  the  Treatment, 

Medical  and   Legal,  of  Insane  Patients.     With  a  Summary  of  the  Laws  in  force  in  the 
United  States  on   the  Confinement  of  the  Insane.     By  Isaac  Ray,  M.  D.     In  one  very 
handsome  octavo  volume  of  471  pages:  extra  cloth,  $3  26.      {Just  Issued.) 
This  volume  is  presented  to  meet  the  want,  so  frequently  expressed,  of  a  comprehensive  trea- 
tise, in  moderate  compass,  on  the  pathology,  diagnosis,  and  treatment  of  insanity.    To  render  it  of 
more  value  to  the  practitioner  in  this  country.  Dr.  Ray  has  added  an  appendix  which  affords  in- 
formation, not  elsewhere  to  be  foundin  so  accessible  aform,  to  physicians  who  may  at  any  moment 
be  called  upon  to  take  action  in  relation  to  patients. 

It  satisfies  a  want  which  must  have  been  sorely  actually  seen  in  practice  and  the  appropriate  treaf- 
felt  by  the  busy  general  practitioners  of  this  couDtry.  '  ment  for  them,  we  find  in  Dr.  Blaudl'ord's  work  a 


It  takes  the  form  of  a  manual  of  clinical  description 
of  the  various  forms  of  insanity,  with  a  description 
of  the  mode  of  examining  persons  suspected  of  in- 
sanity. We  call  particular  attention  to  this  feature 
of  the  book,  as  giving  it  a  unique  value  to  the  gene- 
ral practitioner.  If  we  pass  from  theoretical  conside- 
rations to  descriptions  of  the  varieties  of  insanity  as 


considerable  advance  over  previous  writings  on  the 
subject.  His  pictures  of  the  various  forms  of  mental 
disease  are  so  clear  and  good  that  no  reader  can  fail 
"o  be  struck  with  their  superiority  to  those  given  in 
irdinary  manuals  in  the  English  language  or  (so  far 
as  our  own  reading  extend.sj  in  any  other. — Lv7idon 
Practitioner,  Feb.  1S7I. 


ry^LNSLO  W  (FORBES),  M.D.,  D.  C.L.,  ^c. 

ON  OBSCURE  DISEASES  OF  THE  BRAIN  AND  DISORDERS 

OF  THE  MIND;  their  incipient  Symptoms,  Pathology,  Diagnosis,  Treatment,  and  Pro- 
phylaxis. Second  American,  from  the  third  and  revised  English  edition.  In  one  handsome 
octavo  volume  of  nearly  600  pages,  extra  cloth.     $4  25. 


L 


EA  [HENRY  C). 

■SUPERSTITION    AND    FORCE:    ESSAYS    ON    THE   WAGER   OF 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.  Second  Edition, 
Enlarged.  In  one  handsome  volume  royal  12mo.  of  nearly  500  pages;  extra  cloth,  $2  75. 
{hatel y  Published.) 


We  know  of  no  single  work  which  contains,  in  so 
gmall  a  compass,  so  much  illustrative  of  the  strangest 
operations  of  the  human  mind.  Foot-notes  give  the 
authority  for  each  statement,  showing  vast  research 


interesting  phases  of  human  society  and  progress.  .  . 
The  fulness  and  breadth  with  which  he  has  carried 
out  his  comparative  survey  of  this  repulsive  field  of 
history  [Torture],  are  such  as  to  preclude  our  doing 


and  wonderful  industry.     We  advise  our  confreres  i  justice  to  the  work  within  our  present  limits.     But 


to  read  this  book  and  ponder  its  teachings. — Chicago 
Mtd.  Journal,  Aug.  1S70. 

As  a  work  of  curious  inquiry  on  certain  outlying 
poiats  of  obsolete  law,  "Superstition  aud  Force"  is 
one  of  the  most  remarkable  books  we  have  met  with. 
— London  Athenaiim,  Nov.  A,  18()6. 

He  has  thrown  a  great  deal  of  light  upon  what  must 
be  regarded  as  one  of  the  most  instructive  as  well  as 


here,  as  throughout  the  volume,  there  will  be  found 
a  wealth  of  illustration  aud  a  critical  grasp  of  tlie 
philosophical  import  of  facts  which  will  render  Mr. 
Lea's  labors  of  sterling  value  to  the  historical  stu- 
dent.— London  Saturday  Review,  Oct.  8,  1S70, 

As  a  book  of  ready  reference  on  the  subject,  it  is  of 
the  highest  value. — Westminster  Review,  Oct.  1867. 


B 


r  THE  SAME  AUTHOR.     (Late  y  Published.) 

STUDIES  IN  CHURCH  HISTORY— THE  RISE  OF   THE  TEM- 

PORAL  POWER— BENEFIT  OF  CLERGY— EXCOMMUNICATION.    In  one  large  royal 
12mo.  volume  of  516  pp.  extra  cloth.     $2  75. 
The  story  was  never  told  more   calmly  or  with     literary  phenomenon  that  the  head  of  one  of  the  first 


greater  learning  or  wiser  thought.  We  doubt,  indeed. 
If  any  other  study  of  this  field  can  be  compared  with 
this  for  clearness,  accuracy,  and  power.  —  Chicago 
Examiner,  Dec.  1870. 

Mr  Lea's  latest  work,  "Studies  in  Church  History," 
fully  sustaius  the  promise  of  the  first.  It  deals  with 
tliree  subjects — the  Temporal  Power,  Benefit  of 
Clergy,  and  Excommuuicatiou,  the  record  of  which 
has  a  peculiar  importance  for  the  English  student,  aud 
is  a  chapter  on  Ancient  Law  likely  to  be  regarded  as 
final.  We  can  hardly  pass  from  our  mention  of  such 
Works  as  these — with  which  that  on  "Sacerdotal 
Celibacy"  should  be  included — without  noting  the 


American  houses  is  also  the  writer  of  some  of  its  most 
original  books. — London  Athenceum,  Jan.  7,  1S71 

Mr.  Lea  has  done  great  honor  to  himself  and  this 
country  by  the  admirable  works  he  has  written  on 
ecclesiological  aud  cognate  subjects.  We  have  already 
had  occasion  to  commend  his  "Superstition  and 
Force"  aud  his  "History  of  Sacerdotal  Celibacy." 
The  present  volume  is  fully  as  admirable  in  its  me- 
thod of  dealing  with  topics  aud  in  the  thoroughness — 
a  quality  so  frequently  lackiugin  American  authors — 
vvitli  which  they  are  investigated. — iV.  Y.  Journal  of 
Psychol  Medicine,  July,  1870. 


32 


Henry  C.  Lea's  Publications. 


INDEX    TO    CATALOGCTE. 


American  Journal  of  the  Medical  Sciences 
American  Chemisl  (Tlie)  .... 

Abstract,  Half-Yearly,  of  the  Med   Sciences 
Anatomical  Atlas,  by  Smith  and  Horner 
Anderson  on  Diseases  of  tlie  Sliin 
Ashton  on  the  Kectum  and  Anus  . 
Attfield's  Chemistry      .... 
Ashwell  on  Diseases  of  Females  . 
Ashhurst's  Surgery  .... 

Barnes  on  Diseases  of  Women 
Bryaut's  Practical  Surgery    . 
Blandford  on  Insanity     .... 
Basham  on  Renal  Diseases 
Brinton  on  the  Stomach 
Bigelow  on  the  Hip  .... 

Barclay  s  Medical  Diagnosis  . 
Barlow's  Practice  of  Medicine 
Bowman's  (John  E.)  Practical  Chemistry 
Bowman's  (John  E.)  Medical  Chemistry 
Buckler  on  Bronchitis  .... 
Knmstead  on  Venereal  .... 
Bumstead  and  Cullerier's  Atlas  of  Venereal 
Carpenter's  Human  Physiology  . 
Carpenter's  Comparative  Physiology  . 
Carpenter  on  the  Use  and  Abuse  of  Alcohol 
Carson's  Synopsis  of  Materia  Medica  . 
Chamliers  on  the  Indigestions 
Chambers's  Restorative  Medicine 
Christison  and  Griffith's  Dispensatory 
Churchill's  System  of  Midwifery  . 
Churchill  on  Puerperal  Fever 
Condie  on  Diseases  of  Children  . 
Cooper's  (B.  B  )  Lectures  on  Surgery  . 
Cullerier's  Atlas  of  Venereal  Diseases 
Cyclopedia  of  Practical  Medicine  . 
Dalton's  Human  Physiology  . 
De  Jongh  on  Cod-Liver  Oil  . 
Dewees's  System  of  Midwifery 
Dewees  on  Diseases  of  Femitles 
Dewees  on  Diseases  of  Children  . 
Druitt's  Modern  Surgery 
Dunglison's  Medical  Dictionary  . 
Dunglison's  Human  Physiology  . 
Dunglison  on  Kew  Remedies 
Ellis's  Medical  Formulary,  by  Smith  . 
Erichsen's  System  of  Surgery 
Erichsen  on  Nervous  Injuries 
Flint  on  Respiratory  Organs  . 

Flint  on  tlie  Heart 

Flint's  Pr.ictice  of  Medicine   . 

f  Dwnes's  Elementary  Chemistry  . 

Fox  on  Diseases  of  the  Stomach     . 

Fulleron   the  Lungs,  &c. 

Green's  Pathology  and  Morbid  Anatomy 

Gibson's  Surgery     ..... 

G luge's  Pathological  Histology,  by  Leidy 

Galloway's  Qualitative  Analysis  . 

Gray's  Anatomy 

Griffith's  (R.  E.)  Universal  Formulary 
Gross  on  Foreign  Bodies  in  Air-Passages 
Gross's  Principles  and  Practice  of  Surgery  . 
Gross's  Pathological  Anatomy 
Guersant  on  Surgical  Diseases  of  Children 
Hartshorne's  Essentials  of  Medicine 
Hartshorne's  Conspectus  of  tlie  Medical  Scie 
Hamilton  on  Dislocations  and  Fractures 
Heath's  Practical  Anatomy  . 
Hoblyn's  Medical  Dictionary 

Hodge  on  Women 

Hodge's  Obstetrics 

Hodges'  Practical  Dissections 
Holland's  Medical  Notes  and  Reflections 
Horner's  Anatomy  and  Histology 
Hudson  on  Fevers  .... 

Hill  on  Venereal  Diseases 
Hillier's  Handbook  of  Skin  Diseases 
Jones  and  Sieveking's  Pathological  Anatomy 
Jones  (C.  Handfield)  on  Nervous  Disorders 
Kirkes'  Physiology         ..... 
Knapp's  Chemical  Technology 
Lea's  Saperstition  and  Force 


PAGE 

1 

11 
3 
6 
20 
28 
10 
2.3 
27 
2.3 
29 
31 
IS 
15 
28 
14 
1.) 
10 
10 
17 
19 
19 


vols 


dged 


Lea's  Studies  in  Church  History 

La  Roche  on  Yellow  Fever     . 

La  Roche  on  Pneumonia,  &c. 

Laurence  and  Moon's  Ophthalmic  Surgery 

Lawson  on  the  Eye 

Laycock  on  Medical  Observation 

Lehmann's  Physiological  Chemistry,  2 

Lehmann's  Chemical  Physiology  . 

Ludlow's  Manual  of  Examinations 

Lyons  on  Fever        .... 

Maclise's  Surgical  Anatomy  . 

Marshall's  Physiology    . 

Medical  News  and  Library    . 

Meigs's  Obstetrics,  the  Science  and  the  Art 

Meigs's  Lectures  on  Diseases  of  Women 

Meigs  on  Puerperal  Fever 

Miller's  Practice  of  Surgery  . 

Miller's  Principles  of  Surgery 

Montgomery  on  Pregnancy     . 

Morland  on  Urinary  Organs  . 

Morland  on  Uraemia 

Neill  and  Smith's  Compendium  of  Med.  Science 

Neligan's  Atlas  of  Diseases  of  the  Skin 

Neligan  on  Diseases  of  the  Skin    . 

Obstetrical  Journal  .... 

Odling's  Practical  Chemistry 

Pavy  on  Digestion  .... 

Prize  Essays  on  Consumption 

Parrish's  Practical  Pharmacy 

Pirrie's  System  of  Surgery 

Pereira's  Mat.  Medica  and  Therapeutics,  abri 

Quaiu  and  Sharpey's  Anatomy,  by  Leidy 

Rauking's  Abstract  .... 

Radclitf  and  others  on  the  Nerves,  &c. 

Roberts  on  Urinary  Diseases  . 

Ramsbotbam  on  Parturition  . 

Rigby's  Midwifery 

Rokitansky's  Pathological  Anatomy     . 
Royle's  Materia  Medica  and  Therapeutics 

Salter  on  Asthma 

Swayne's  Obstetric  Aphorisms 

Sargent's  Minor  Surgery 

Sharpey  and  Quain's  Anatomy,  by  Leidy 

Simon's  General  Pathology     . 

Skey's  Operative  Surgery 

Slade  on  Diphtheria        .... 

Smith  |J.  L.)  on  Children 

Smith  (H.  H.)  and  Horner's  Anatomical  Atlas 

Smith  (Edward)  ou  Consumption  . 

Smith  on  Wasting  Diseases  of  Children 

Solly  on  Anatomy  and  Diseases  of  the  Brai 

Still'6's  Therapeutics 

Tanner's  JIanual  of  Cliuical  Medicine 

Tanner  on  Pregnancy 

Taylor's  Medical  Jurisprudence     . 

Taylor's  Principles  and  Piiictice  of  Med    Jurisp 

Tuke  on  the  Intlueuce  of  the  .Mind 

Thomas  on  Diseases  of  Females    . 

Thompson  oo  Urinary  Organs 

Thomp-on  on  Stricture    . 

Todd  on  Acute  Diseases  . 

Wales  on  Surgical  Operations 

Walshe  on  the  Heart      .        .        . 

Watson's  Practice  of  Physic  . 

Wells  on  the  Eye    .... 

West  on  Diseases  of  Females 

West  on  Diseases  of  Children 

West  on  Nervous  Disorders  of  Children 

West  on  Ulceration  of  Os  Uteri 

What  to  Observe  in  Medical  Cases 

Williams's  Principles  of  Medicine 

Williams  on  Consumption 

Wilson's  Human  Anatomy     . 

Wilson  on  Diseases  of  the  Skin 

Wilson's  Plates  on  Diseases  of  the  Ski 

Wilson's  Handbook  of  Cutaneous  Medicine 

Wilson  on  Spermatorrhoea 

Winslow  on  Brain  and  Miu'l 

Wiihler's  Organic  Chfimistry 

Winckel  ou  Chililbed 

Zeissl  on  Venereal  . 


PAOB 
31 


y  '^':-  ■  '7- 

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